Member Forms
Click on any of the links to view or print these Delta Dental of Illinois materials.
Group Member Forms
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
Individual Member Forms
Individual Member 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
Application
PLEASE NOTE: WE DO NOT ACCEPT APPLICATIONS OR CREDIT CARD INFORMATION BY EMAIL. THE EASIEST WAY IS TO ENROLL ONLINE. HOWEVER, NOT ALL OF OUR PLANS OFFER ONLINE ENROLLMENT. IF YOU MUST COMPLETE A PAPER APPLICATION, PLEASE MAIL IT TO:
DELTA DENTAL OF ILLINOIS
P.O. Box 103
Stevens Point, WI 54481
All Member Forms
Grievance 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. To complete with a digital signature and send electronically, please download this form with Adobe or another PDF reader.
Privacy Notice (GLB)
Terms and Conditions
Certification of Parental or Legal Guardian Rights
Non-Discrimination Notice