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February 5, 2012
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Direct Deposit Authorization Form
You now have the option for direct deposit for Delta Dental of Illinois payments. Direct Deposit of funds is a safe, easy and efficient transaction allowing weekly deposits directly into the bank account designated. You have the option of receiving direct deposit Explanation of Payments (EOP) either by e-mail notification of bank deposits with delivery of EOPs to Delta Dental of Illinois' Web site or by fax notification and faxed EOPs.

Patient Consent Form
Delta Dental of Illinois has created a patient consent form for optional or non-covered treatment. Please retain a copy of this worksheet as proof of consent for treatment.

Claim Form
This form should be used for Delta Dental PPO and Delta Dental Premier claims.  Please do not use it for DeltaCare.

DeltaCare Claim Form
Please use this form for DeltaCare specialty claims.  You must submit with a DeltaCare Specialty Referral Form if applicable.

DeltaCare DHMO Encounter Form

DeltaCare Specialty Referral Form

DeltaCare Specialty Facility Listing
If you need to refer one of your DeltaCare patients to a specialist, please use this listing.  It is updated monthly.

W-9

Claims Appeal Procedures Summary

Claims Appeal Procudures Detailed Description