If you do not have the Adobe Acrobat Reader plug-in, you will need to download it to view and print the claim form. Click on the image below to download the plug-in if you don't have it installed.

If you are visiting a non-Delta Dental dentist, complete items 1 through 15 on the claim form and attach a copy of the dentist's statement of treatment, including the dentist's name and phone number (with area code). Delta Dental will use the dentist's statement to process the claim. It's very important that the statement include a description of each service the dentist performs.

Once completed, make a copy of the form for your records and mail the original to the address on the form.

Ready to download and print a claim form?
Click here.

When visiting a Delta Dental dentist, the dental office completes and submits a claim form to Delta Dental on your behalf.
You do not need to bring a claim form if you are receiving treatment from a Delta Dental dentist.