Texas A&M University

Current Location: Texas A&M University System employees & retirees home page > Print claim form

Download and print a claim form

If you do not have the Adobe Acrobat Reader plug-in, you will need to download it to view and print the claim form.

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.

Stop and read this before you download the claim form!

You don't need to complete a claim form when you visit a Delta Dental dentist since the dental office does it on your behalf. That is one of the benefits of the Delta Dental Difference^SM!

You only need to follow the steps outlined on this page when visiting a non-Delta Dental dentist.

Ready to download and print a claim form? Just click here.

IMPORTANT NOTE: Claims incurred during the Plan Year (January 1 through December 31) should be submitted no later than the March 31 immediately following the Plan Year in which services were incurred. Claims submitted after that time will be denied.