This notice describes how medical information about you may be used and disclosed and how you can get access to this information.
This notice is effective as of January 1, 2022.
Download our website Terms and Conditions
By accessing and/or utilizing the information on this website, you acknowledge and agree to the terms and conditions above.
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Download our authorization form.
- An authorization is a written document, signed by the patient/subscriber or his/her personal representative, that specifically allows Delta Dental of Missouri to disclose PHI with permission.
- Delta Dental must obtain express authorization for disclosure of PHI that is not for TPO (Treatment, Payment and Operations) or not otherwise authorized by HIPAA.
- The authorization must be in writing, and the form must contain specific requirements mandated by HIPAA.
- Delta Dental may not condition treatment upon authorization.
- Completed authorization forms can be faxed to 314-656-2900 or mailed to Delta Dental of Missouri; 12399 Gravois Road; St. Louis, MO 63127.
The authorization is revocable at will at any time.