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.

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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

• 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.
• International Claim Form | International Claims Instructions
• Claims Appeal Summary
• Claims Appeal Procedures
• Enrollment/Change of Status/Waiver Form 

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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 Summary
• Claims Appeal Procedures

Applications for Individual Dental and Vision Coverage 

• Individual Dental Application
• Individual Vision Application

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

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All Member Forms

Submit a Grievance

• Grievance Form

Dentist Referral Form

• Dentist Referral Form

Privacy

• HIPAA Notice of Privacy 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. To complete with a digital signature and send electronically, please download this form with Adobe or another PDF reader.
• Privacy Notice (GLB)
• Terms and Conditions
• Certification of Parental or Legal Guardian Rights
• Non-Discrimination Notice