IL - Subscriber - Refer Your Dentist

February 5, 2012

If you have checked our Delta Dentist Locator and found that your provider is not a Delta Dental member, please provide answers to the questions below and send it to us via e-mail. Dentists accepted by Delta Dental must first meet certain qualifying criteria. Thank you for your recommendation and interest in Delta Dental.

To refer your dentist to Delta Dental, please provide the following information:

Your Name
Your Email
Your Phone
Group/Employer's Name

Dental Office Name
Dentist's Name
Address

City
State		ZIP
Phone
Specialty (if applicable)

I would like the dentist to join:	Delta Dental PPO Delta Dental Premier DeltaCare DHMO

Additional comments (optional):

Is it okay for us to use your name when contacting the dentist?

Yes - you may mention my name.
No - I prefer you not to mention my name.

*A network referral is not a guarantee of dentist participation in a Delta Dental network. Delta Dental's network dentists must meet qualifying criteria to join a network. If the dentist meets qualifying criteria and agrees to join a Delta Dental network(s), he or she will be added to the applicable network(s). You can check dentist participation online at www.deltadentalil.com through the Dentist Search or by calling 800-323-1743 and accessing our automated system or speaking to a customer service representative.