Delta Dental Claims Forms

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.