Member Forms

Click on any of the links to view or print these Delta Dental of Illinois materials.

Note: You may need to download the form with Adobe or another PDF reader if you'd like to fill in the form electronically on a computer or other digital device.


Group Member Forms

Claims and Enrollment

PLEASE NOTE: CLAIMS APPEALS SHOULD BE SENT TO THE STREET ADDRESS BELOW, NOT THE P.O. BOX. THE P.O. BOX IS FOR CLAIMS ONLY. CLAIMS APPEALS SENT TO THE P.O. BOX WILL BE DELAYED.

CLAIMS APPEAL
Attn: Re-Evaluation Committee
111 Shuman Blvd. Naperville, IL 60563

Submit a Claim


Individual Member Forms

Claims

PLEASE NOTE: CLAIMS APPEALS SHOULD BE SENT TO THE STREET ADDRESS BELOW, NOT THE P.O. BOX. THE P.O. BOX IS FOR CLAIMS ONLY. CLAIMS APPEALS SENT TO THE P.O. BOX WILL BE DELAYED.

CLAIMS APPEAL
Attn: Re-Evaluation Committee
111 Shuman Blvd. Naperville, IL 60563

  • Individual Member 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.
  • Claims Appeal Procedures

Submit a Claim


Applications for Individual Dental and Vision Coverage 

ENROLL ONLINE. HOWEVER, NOT ALL OF OUR PLANS OFFER ONLINE ENROLLMENT. IF YOU MUST COMPLETE A PAPER APPLICATION, PLEASE MAIL IT TO:

DELTA DENTAL OF ILLINOIS
P.O. Box 103
Stevens Point, WI 54481


All Member Forms

Submit a Grievance

Dentist Referral Form

Privacy