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Forms and Resources

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Materials and Forms


Enrollment Forms
Enrollment/Change of Status/Waiver Form


Claim Forms

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.


DeltaCare Claim Form

This claim form is for DeltaCare specialty claims.  DeltaCare specialists submit claim forms for DeltaCare patients.


Specialty Facility Listing


Dentist Referral Form

Dentist Referral Form


Delta Dental of Illinois HIPAA, Privacy, Parental Rights and Continuation of Coverage Notices and Forms
HIPAA Notice of Privacy Practice and Rights
Authorization for Release of Information
Privacy Notice (GLB)
Certification of Parental or Legal Guardian Rights
Continuation of Coverage Appendix

Non-Discrimination Notice

Web Terms and Conditions

Claim Appeal Information
Claim Appeal Summary
Claims Appeal Procedures



Solicitud de Seguro Dental Individual

Aviso de No Discriminación

Términos y Condiciones de Uso

Notificatión Sobre Derechos y Prácticas de Privacidad


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Your Mouth Matters

Benefit from oral health knowledge

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Giving Back

Our Foundation -- Improving Oral Health

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Customer Service

We're here to help, 24/7.

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