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Forms

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.

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.

Direct Deposit Information

Application

Credentialing Forms

Please complete these forms to enroll in the Delta Dental PPOSM Network: 

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