Looking for a form? You’ll find all our electronic and downloadable forms here, organized by topic and plan type.
Delta Dental dentists will file claims for you. But if you decide to visit a non-Delta Dental dentist, you may need to file one of the following claim forms:
Do you want to contact Customer Service online? Fill out the form, and we’ll get back to you via email.
Delta Dental PPO, DPO and Delta Dental Premier:
- Alabama, Florida, Georgia, Louisiana, Mississippi, Montana, Nevada, Texas or Utah
- Delaware, District of Columbia, New York, Pennsylvania, Maryland or West Virginia
DeltaCare USA and DeltaVision®:
If you have a grievance, submit the relevant form for your plan:
- Delta Dental PPO, DPO and Delta Dental Premier
- Other languages: español | 中文 343 KB
- DeltaCare USA
- Other languages: español | 中文 183 KB
- Other languages: español | 中文 286 KB
- Denti-Cal/State, County and Local Dental Programs
- Other languages: español | 中文 162 KB
- DeltaCare USA Continuous Orthodontic Coverage 26 KB
- If you or an eligible member of your family has started orthodontic treatment under a previous dental plan sponsored by an employer/organization, you may be able to continue that coverage when you switch to a DeltaCare USA plan. Please have your treating orthodontist complete and submit this form along with a claim form within 30 days of your new plan’s effective date.
- Disclosure of Health Information 85 KB
- This form authorizes Delta Dental to release your health information to an appointed representative, such as a family member.