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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.