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February 5, 2012
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GROUP APPLICATIONS
- Delta Dental of Illinois Group Application and New Group Summary Document (50+ benefit eligible employees)
- Delta Dental of Illinois Pool Group Application (2-49 benefit eligible employees)
DELTA DENTAL OF ILLINOIS ENROLLMENT FORMS
- Enrollment/Change of Status/Waiver -- Delta Dental of Illinois Enrollment/Change of Status/Waiver form for all Delta Dental programs.
CLAIM FORMS
- Claim Form
This claim form is for Delta Dental PPO and Delta Dental Premier claims. Delta Dental PPO and Delta Dental Premier network dentists submit claim forms automatically on behalf of Delta Dental paitents. You can download this form, insert the necessary information, and print it or you can print it and fill in the applicable information.
- DeltaCare Claim Form
This claim form is for DeltaCare specialty claims. DeltaCare specialists submit claim forms for DeltaCare patients.
INDIVIDUAL DENTAL PLANS
DENTIST REFERRAL FORM
- Dentist Referral Form
Before you use this PDF form, try our online referral.
DELTA DENTAL OF ILLINOIS' HIPAA PRIVACY NOTICE & AUTHORIZATION FOR RELEASE OF INFORMATION
- HIPAA Notice of Privacy Practice and Rights
- HIPAA Notice of Privacy Practice and Rights (Spanish)
- Authorization for Release of Information
This is an authorization form required to authorize Delta Dental of Illinois to release individually identified health information - Privacy Notice (GLB)
- Privacy Notice (GLB) (Spanish)
CLAIM APPEAL INFORMATION
CERTIFICATION OF PARENTAL OF LEGAL GUARDIAN RIGHTS
CONTINUATION OF COVERAGE