Notice
Change Healthcare announced a breach of HIPAA privacy and is reaching out to individuals whose personal information may have been compromised. Although this incident does not involve Delta Dental of New Jersey or Connecticut, Change Healthcare is a vendor we used and we are providing this information to help our members who might be affected.
Guidelines for Submitting Small Group Authorization Forms Granting Access to PHI (“HIPAA Forms”)
Delta Dental of Connecticut Insured Clients
Complete Authorized Appointee – this should be the individual at the group who is authorized to appoint others to have access to information. This person will sign the bottom of the access from.
Complete Group Dental Plan Name – this is the group name.
Complete Group Dental Plan Number(s) – the ten-digit number(s) that appear(s) on the group’s contract and invoices.
List each of the individual(s) who should be given access to PHI and their different roles: view, modify, and password. This section grants authorization to specified individuals to receive protected health information. Please carefully consider who is listed on the form and the access level. There can be one or more authorized individuals for the group. Individuals listed on this form could receive information such as participant/member names, Social Security numbers, birth dates, and addresses. In addition, depending on the authorization level, that person may be able to access and modify eligibility on our system. We will not provide information to individuals not listed in this section.
Authorized signature – must be the same person that is authorized to appoint others with access.
Please note: any time an authorized individual leaves your group, or a new authorized individual joins your group, you should notify Delta Dental immediately. Each time Delta Dental receives a HIPAA form, it replaces / supersedes existing forms unless otherwise noted.
Download form
Complete Group Dental Plan Name – this is the group name.
Complete Group Dental Plan Number(s) – the ten-digit number(s) that appear(s) on the group’s contract and invoices.
List each of the individual(s) who should be given access to PHI and their different roles: view, modify, and password. This section grants authorization to specified individuals to receive protected health information. Please carefully consider who is listed on the form and the access level. There can be one or more authorized individuals for the group. Individuals listed on this form could receive information such as participant/member names, Social Security numbers, birth dates, and addresses. In addition, depending on the authorization level, that person may be able to access and modify eligibility on our system. We will not provide information to individuals not listed in this section.
- View – allows a person access to view and receive enrollment reports or information (no password to access web portal).
- Modify – allows a person to view and receive enrollment reports or information; and allows a person to add and delete eligibility. Also allows a person to modify enrolled employee and dependent information, such as addresses, for our group dental benefit plan (no password to access web portal).
- Password (includes View and Modify through the web portal) – allows a person to obtain a password to access the web portal to view and modify Enrollment Data.
Authorized signature – must be the same person that is authorized to appoint others with access.
Please note: any time an authorized individual leaves your group, or a new authorized individual joins your group, you should notify Delta Dental immediately. Each time Delta Dental receives a HIPAA form, it replaces / supersedes existing forms unless otherwise noted.
Delta Dental of Connecticut is a part of Delta Dental Plans Association. Through our national network of Delta Dental companies, we offer dental coverage in all 50 states, Puerto Rico and other U.S. territories.
