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Fraud Complaint Form

Please complete and submit the following form to report possible fraudulent activity to Delta Dental of Illinois. You may also report your concerns by calling us at 888-328-9343.

NOTE: If you choose to submit your complaint online, please be advised that communications submitted through the Internet are not considered secure. Although it is unlikely, there is a possibility that information you include in electronic communications (online and email) can be intercepted and read by other parties besides the person to whom it is addressed. Please do not include any sensitive protected health information, such as your Social Security number or birth date in electronic communications you send to us.

All fields marked with * are required.

Fraudulent Activity

Please provide as much information as possible so a thorough investigation can be conducted.

Describe the fraudulent activity you would like to report *

Claim number associated to this activiy

Patient name associated to this activity

Member ID associated to this activity (Note: please do not provide SSN)

Submitter has documentation they are willing to provide if requested

Name and information of the individual or facility performing the potential fraudulent activity

Name *

Facility or provider office name

Address Line 1 *

Address Line 2

City *

State *

Zip Code *

Email Address

Phone Number

Submitter's Information

Name *

Email Address *

Phone Number

Agree to Terms of Use *

By submitting this form, I am agreeing to the Terms of Use.

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Fraud Complaint Form