Notice:
Our offices will be closed Monday, September 2 in honor of Labor Day. We will reopen September 3, at 6am Pacific Time.
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.
