Member Forms

Click on any of the links to view or print these Delta Dental of Illinois materials.

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.

Group Member Forms

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.

International Claim Form | International Claims Instructions

PLEASE NOTE: CLAIMS APPEALS SHOULD BE SENT TO THE STREET ADDRESS BELOW, NOT THE P.O. BOX. THE P.O. BOX IS FOR CLAIMS ONLY. CLAIMS APPEALS SENT TO THE P.O. 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
• 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 P.O. BOX. THE P.O. BOX IS FOR CLAIMS ONLY. CLAIMS APPEALS SENT TO THE P.O. BOX WILL BE DELAYED.

CLAIMS APPEAL
Attn: Re-Evaluation Committee
111 Shuman Blvd. Naperville, IL 60563

• Claims Appeal Summary
• Claims Appeal Procedures
• Individual Dental Application
• Individual Vision 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