Resources


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Forms and Resources

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Materials and Forms

Enrollment Forms

Enrollment/Change of Status/Waiver Form

Billing Change Forms

Update/Change Credit Card or EFT payment information.

Claim 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.

Dentist Referral Form

Dentist Referral Form

Delta Dental of Illinois HIPAA, Privacy, Parental Rights and Continuation of Coverage Notices and Forms

HIPAA Notice of Privacy Practice 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
Continuation of Coverage Appendix
Non-Discrimination Notice

Claim Appeal Information

Claim Appeal Summary
Claims Appeal Procedures

Formas Españolas

Solicitud de Seguro Dental Individual
Aviso de No Discriminación
Términos y Condiciones de Uso
Notificatión Sobre Derechos y Prácticas de Privacidad


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