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Materials and Forms

Click on any of the links to view or print these Delta Dental of Illinois materials.

Group Applications

Small Group Application (2-100* lives)

Group Application (2-100* lives)

Group New Group Implementation Form (2-100* lives)

*Effective January 1, 2016

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.

DeltaVision Non-Network Claim Form

Dentist Referral Form

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
Certification of Parental or Legal Guardian Rights
Continuation of Coverage Appendix

Claim Appeal Information
Claim Appeal Summary
Claims Appeal Procedures


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Giving Back

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Customer Service

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