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Click on any of the links to view or print these Delta Dental of Illinois materials.
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.
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
Enrollment/Change of Status/Waiver Form
Dentist Referral Form
HIPAA Notice of Privacy and Rights
Authorization for Release of Information This is an authorization form required to authorize Delta Dental of Illinois to release individually identified health information.
Privacy Notice (GLB)
Terms and Conditions
Certification of Parental or Legal Guardian Rights
Non-Discrimination Notice
Forma de Reclamo
Aviso de No Discriminación
Términos y Condiciones de Uso
Notificatión Sobre Derechos y Prácticas de Privacidad