Submit a Grievance

You can complete an online grievance form below, or email, fax or mail a grievance form to us.

NOTE: If you choose to submit your grievance 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. You always have the option of submitting a grievance by mail or fax. 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.

Note the above disclaimer and complete our Grievance Form PDF and email it to prgrievance@deltadentalil.com

You may also fax a completed Grievance Form PDF to 630-300-5547 or mail it to Delta Dental of Illinois, 111 Shuman Blvd, Naperville, IL 60563, Attention: Grievance Committee

If you have any questions, please contact us at 800-323-1743.

All fields marked with * are required.

Delta Dental of Illinois Member Grievance Form

Date of Form Submittal *

Member/Patient Information

Primary Member Name (policyholder) *

Primary Member's Date of Birth (DOB) *

Patient Name *

Daytime Phone Number *

Email Address *

Information on Issue to be Addressed

The issue concerns: *

Billing
Treatment of Care
Denied Claim(s)
Frequency Limitation
Other - please list below

Please list Other Issue to be Addressed

Treating Dentist *

Dental Office

Office Address *

City *

State *

Zip Code *

Date of Service *

Claim Number (if applicable)

Is the treating dentist aware of your issue? *

If yes, what was their response?

If the dentist is not aware of the issue, why not?

Have you sought a second opinion from another dentist? *

If yes, what was the outcome?

Please describe the nature of your grievance (If you are experiencing pain or discomfort, please include the nature and severity of the pain.) *

What is your desired outcome in submitting this grievance? *

If an agreeable solution can be reached, would you return to the treating dentist? *

Menu

I am a ...

Submit a Grievance

Member/Patient Information

Information on Issue to be Addressed