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Forms and Resources

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Individual Member Forms

Enrollment Forms

Enrollment/Change of Status/Waiver Form

Billing Change Forms

Update/Change Credit Card or EFT payment information

Claim Forms

Individual Claim Form - This claim form is for Delta Dental PPO℠, Delta Dental Premier® and non-network claims.  Delta Dental PPO and Delta Dental Premier network dentists submit claim forms automatically on behalf of Delta Dental patients. You can download this form, insert the necessary information, and print it or you can print it and fill in the applicable information.

 

Group Member Forms

Enrollment Forms

Enrollment/Change of Status/Waiver Form

Billing Change Forms

Update/Change Credit Card or EFT payment information

Claim Forms

Group Claim Form - This claim form is for Delta Dental PPO℠, Delta Dental Premier® and non-network claims.  Delta Dental PPO and Delta Dental Premier network dentists submit claim forms automatically on behalf of Delta Dental patients. You can download this form, insert the necessary information, and print it or you can print it and fill in the applicable information.

 

General Forms

DeltaCare

Specialty Facility Listing

DeltaCare Claim Form - This claim form is for DeltaCare specialty claims.  DeltaCare specialists submit claim forms for DeltaCare patients.

Dentist Referral Form

Dentist Referral Form

Delta Dental of Illinois HIPAA, Privacy, Parental Rights and Continuation of Coverage Notices and Forms

HIPAA Notice of Privacy Practice and Rights

Authorization for Release of Information - This is an authorization form required to authorize Delta Dental of Illinois to release individually identified health information

Privacy Notice (GLB)

Terms and Conditions

Certification of Parental or Legal Guardian Rights

Continuation of Coverage Appendix

Non-Discrimination Notice

Claim Appeal Information

Claim Appeal Summary

Claims Appeal Procedures

 

Formas Españolas

Solicitud de Seguro Dental Individual

Aviso de No Discriminación

Términos y Condiciones de Uso

Notificatión Sobre Derechos y Prácticas de Privacidad

 

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