Forms

Note: You may need to download the form with Adobe or another PDF reader if you'd like to fill in the form electronically on a computer or other digital device.

Delta Dental PPO℠ and Premier® Claim Forms

Individual 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.

Group 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.

See our helpful guide for tips on quicker processing and payment of claims.

DeltaCare®

• Encounter Form
• Specialty Listing
• DeltaCare Specialty Claim Form
  • ​This claim form is for DeltaCare specialty claims. DeltaCare specialists submit claim forms for DeltaCare patients.
• DeltaCare Specialty Referral Form
  • ​This referral form is for DeltaCare primary dentists to use to refer a DeltaCare member to a DeltaCare specialty dentist. The DeltaCare specialty listing can be accessed through the Specialty Listing link above.

Direct Deposit Information

• Application

Credentialing Forms

Please complete these forms to enroll in the Delta Dental PPO^SM Network: 

• PPO Enrollment Checklist
• PPO Agreement
• Credentialing Form
• Recredentialing Form
• Direct Deposit
• Tax ID Change Form

Delta Dental of Illinois HIPAA and Privacy Forms

• HIPAA Notice of Privacy Practice and Rights
• Terms and Conditions

Claim Appeal Information

Please note: CLAIMS APPEALS SHOULD BE SENT TO THE STREET ADDRESS BELOW NOT THE PO BOX. THE PO BOX IS FOR CLAIMS ONLY. CLAIMS APPEALS SENT TO THE PO BOX WILL BE DELAYED.

Claims Appeal
Attn: Re-Evaluation Committee
111 Shuman Blvd. Naperville, IL 60563

• Claims Appeal Summary
• Claims Appeal Procedures