Forms
Find the forms and information you need to join our networks, update your information, submit clinical information, or manage your DeltaCare patients.
Applications: Member Dentist, new location, recredentialing and non-participating provider
Securely complete online applications to join our network, add a location or practice, recredential your TIN (every 3 years), or submit claims as an out-of-network provider.
Become a Member Dentist
If you’re interested in becoming a Member Dentist, we make the process easy. Simply follow these steps to join our Delta Dental Premier network. You can also choose within this packet to join the Delta Dental PPO network at the same time.
1. Review the Member Dentist Rules and Regulations
Downloadable Form
2. Complete the application
Online Fillable Form
Add a practice or location to your Delta Dental membership
If you're already a Delta Dental Member Dentist and want to contract at an additional location, follow the steps below.
1. Review the Member Dentist Rules and Regulations
Downloadable Form
2. Complete the application
Online Fillable Form
Re-credentialing application
Member Dentists are required to be recredentialed every 3 years. Prior to your recredentialing due date, we’ll notify you via the email we have on file when your membership is due for recredentialing. We’ll send you an email confirmation once your completed application has been approved.
Re-credentialing packet
Online Fillable Form
Non-Participating Provider Application
Use this form if you're not a participating provider with us and have submitted a claim. We'll use your information to update our records and process the claim accordingly. You may also need this form if you're a Denturist, Hygienist, Physician or Anesthesiologist.
Complete the Non-Participating Provider Application through DocuSign
Online Fillable Form
Business information forms
Securely complete online requests to update your address, change your specialty or TIN, enroll in direct deposit, and update your membership or network status.
Address change form
Use this form to change your payment and/or service office address(es). We’ll process your address change(s) within 7-10 days of receiving your completed form.
Tax ID Number (TIN) change notification
Use this form to notify us of a TIN change. We’ll process your completed notification within 7-10 days.
Specialty change request form
Use this form if you are changing from one specialty to another. We’ll process your completed request within 18-21 days.
Termination request form
To fulfill your requirement of providing written notice if leaving a location or terminating an aspect of your membership, submit this form if you're: closing a service office, terminating network membership/participation, retiring, leaving a specific location, or moving out of state.
We'll review your completed request within 7-10 days (note: the effective date is dependent on contractual obligations).
Direct deposit form (available to Washington State providers only)
If you're a Washington State dentist, use this form to sign up for direct deposit and Electronic Remittance Advice (ERA) for claims payment from DDWA and Out of State Delta Dentals. For instructions on how to complete this form, click here. We’ll process your completed request within 7-10 days.
Note: We require all offices that operate under the same TIN to be reimbursed using the same method. If you sign up for direct deposit, the same direct deposit information will be used for all providers with the TIN. Click here to learn more.
W-9 form
Use this form to report your TIN information or to change the address on file for the yearly sending of 1099 statements. We’ll process your completed request within 7-10 days.
Clinical forms
Find instructions and forms for claims submissions, orthodontic medical necessity preauthorization, and time limitation exceptions.
Claims forms
Locate, complete, and submit the claim form that meets your needs.
Orthodontic medical necessity form
Complete this form when a group requires a preauthorization to determine the medical necessity of orthodontic treatment (Class 22).
Time Limitation Exception Form
Most dental procedures covered by our plans include a time limitation to allow benefit payment. For example, tooth surfaces treated with a direct restoration are generally covered once every two years.
Use this form only when requesting review of a dental procedure previously adjudicated as not billable to the patient due to a time limitation policy, and when extenuating clinical circumstances exist (i.e, this form is not to be used for standard claim submissions).
All claims remain subject to group filing requirements and will not be reviewed or reprocessed beyond a group’s filing period. Exceptions to our clinical criteria will also not be considered to allow benefit.
Additional payment with regard to contract time and frequency limitations will not be considered, and an approved exception may only change a claim adjudication from “not billable” to “patient responsibility” pending review.
Email completed Time Limitation Exception Forms to ClinicalReviewProcessing@DeltaDentalWA.com.
DeltaCare® forms
Click on the links below to access and complete the forms you need to manage your DeltaCare® practice and patients.
DeltaCare® Dentist Status Change Form
After you've connected with a Provider Ambassador about your DeltaCare® status, use this form to update if your practice is currently open or closed to accept new DeltaCare® patients as their Primary Care Dentist (PCD). We’ll process your status change and notify you within 7-10 days of receiving your completed form.
DeltaCare® Specialty Referral Form
Use this form to refer your patient to a specialist. (Note: you don’t have to complete this form for orthodontic referrals).
Adult - Optional Treatment Consent Form
Use this form when a patient elects to receive optional treatment.
Pediatric - Optional Treatment Consent Form
Use this form when a parent or guardian elects an optional treatment for their child.
About DeltaCare
DeltaCare is Delta Dental of Washington’s managed care plan. Patients choose their Primary Care Dentist (PCD), who serves as DeltaCare patients primary oral healthcare provider and can also refer those patients to participating DeltaCare Specialists when needed, and . For questions on DeltaCare, email MyDDWAAmbassador@DeltaDentalWA.com.
Forms on this page
- Become a Member Dentist
- Add a practice or location
- Re-credentialing application
- Non-Participating Provider Application
- Address change
- Tax Id number(TIN) change
- Specialty change request
- Termination request
- Direct deposit
- W-9 form
- Claims forms
- Orthodontic medical necessity
- Time Limitation Exception
- Non-Participating Provider Application
- DeltaCare® Dentist Status Change
- DeltaCare® Specialty Referral
- Adult - Optional Treatment Consent
- Pediatric - Optional Treatment Consent
