Delta Dental Claims Forms
Get your claim started by submitting one of the standard forms that relates to your needs.
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Standard Claim Form
Use this form to file a claim for services performed inside the United States. -
Coordination of Benefits Questionnaire
Use this form when coordinating dental benefits with another dental coverage provider (e.g., your spouse's coverage). -
Subscriber Appeals Form
Use this form to file an appeal of an adverse benefit determination. -
Out of the Country Claim Form
Use this form to file a claim for services performed outside the United States. -
Authorized Representative Form for Appeals
Use this form when you have chosen a representative to assist with your appeal. This will allow Delta Dental of Washington to release relevant information to the chosen party. -
HIPAA Authorization Form
Use this form to view overage dependents information or if you're having custody issues.
