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
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 OR FAX. 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:
CONSUMER DIRECT - INDIVIDUAL PLANS
DELTA DENTAL OF ILLINOIS
P.O. Box 3384
Lisle, IL 60532
Billing Change Form
This form is to update or change your payment information.
PLEASE NOTE: WE DO NOT ACCEPT CREDIT CARD INFORMATION BY EMAIL OR FAX. THE EASIEST WAY IS TO UPDATE YOUR BILLING INFORMATION IS THROUGH THE SECURE PORTAL ONLINE. IF YOU MUST COMPLETE A PAPER BILLING CHANGE FORM, PLEASE MAIL IT TO:
CONSUMER DIRECT - INDIVIDUAL PLANS
DELTA DENTAL OF ILLINOIS
P.O. Box 3384
Lisle, IL 60532
All Member Forms
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
Formas Españolas
Formas de Miembros de Grupo
Forma de Reclamo
Aviso de No Discriminación
Términos y Condiciones de Uso
Notificatión Sobre Derechos y Prácticas de Privacidad
Formas Individual
Forma de Reclamo
Solicitud de Seguro Dental Individual
Aviso de No Discriminación
Términos y Condiciones de Uso
Notificatión Sobre Derechos y Prácticas de Privacidad