Benefits Administrators

Claim Forms

Delta Dental PPO and Delta Dental Premier claim forms by administrator.

• Delta Dental of California
• Delta Dental of Delaware
• Delta Dental of the District of Columbia
• Delta Dental Insurance Company
• Delta Dental of New York
• Delta Dental of Pennsylvania
• Delta Dental of West Virginia

DeltaCare USA claim and encounter forms.

• DeltaCare USA claim form
• DeltaCare USA encounter form
• DeltaVision encounter form

Claim forms for AARP Dental Insurance Plan.

• AARP Dental Insurance Plan

Customer Service Forms

For fastest response, select the form for the company through which you receive benefits.

• Delta Dental PP0 (DPO in Texas) and Delta Dental Premier Customer Service Forms for:
  • Alabama, Florida, Georgia, Louisiana, Mississippi, Montana, Nevada, Texas or Utah
  • Delaware, District of Columbia, New York, Pennsylvania, Maryland or West Virginia
  • California
• DeltaCare USA Customer Service Form
• Online Services Login Service Form

Grievance Forms by Program

We urge you to communicate directly with your dentist. If you cannot obtain a satisfactory resolution, file an online grievance report or call customer service.

• Delta Dental PPO and Delta Dental Premier
• DeltaCare USA
• DeltaVision
• Denti-Cal/State, County and Local Dental Programs