Materials and Forms
Click on any of the links to view or print these Delta Dental of Illinois materials.
*Effective January 1, 2016
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.
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
This is an authorization form required to authorize Delta Dental of Illinois to release individually identified health information.