Materials and Forms
Click on any of the links to view or print these Delta Dental of Illinois materials.
Enrollment/Change of Status/Waiver 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 paitents. You can download this form, insert the necessary information, and print it or you can print it and fill in the applicable information.
This claim form is for DeltaCare specialty claims. DeltaCare specialists submit claim forms for DeltaCare patients.
Dentist Referral Form
Parental Rights and Continuation of Coverage Notices and Forms
Authorization for Release of Information
This is an authorization form required to authorize Delta Dental of Illinois to release individually identified health information
HIPAA Notice of Privacy Practice and Rights
Privacy Notice (GLB)
Certification of Parental or Legal Guardian Rights
Continuation of Coverage Appendix
Claim Appeal Information
Claim Appeal Summary
Claims Appeal Procedures