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Refer a Dentist Form

Recently switched dental plans or looking to make the most of your dental benefits? Delta Dental of Illinois offers numerous benefits that may prompt our members to recommend their dentist to join our network. To refer your dentist to our network, kindly complete the form below. *Please contact the dentist below about joining Delta Dental’s networks.*

*A network referral is not a guarantee of dentist participation in a Delta Dental network. Delta Dental’s network dentists must meet qualifying criteria to join a network. If the dentist meets the qualifying criteria and agrees to join a Delta Dental network(s), he or she will be added to the applicable network(s). You can check dentist participation online at www.deltadentalil.com through the "Find a Provider" feature or by calling 800-323-1743 and accessing our automated system or speaking to a customer service representative.

All fields marked with * are required.

Dentist Information

Dentist Name: *

Dental Office Name: *

Dental Office Street Address: *

Dental Office City, State, ZIP:

Dental Office Phone: *

Dental Specialty if Applicable

Select the network(s) you want the dentist to join: *

Delta Dental PPO
Delta Dental Premier
DeltaCare DHMO

Your Information

Your Name: *

Your Group/Employer's Name if Applicable:

Your Phone:

Your Email: *

You may use my name when you contact my dentist.

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Refer a Dentist Form

Smart Plans for Smart Mouths