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Delta Dental Insurance Administrative Forms

Administrative and claim forms

Find all of the forms needed for claims, authorizations and more.

Claim Forms

For DeltaCare® USA claims and encounters.

 DeltaCare USA claim form

 DeltaCare USA encounter form

Dentist Administrative Forms and Resources

 DCUSA Continuous Orthodontic Coverage Form
 DCUSA Elective Procedure Form
 DCUSA Emergency Pre-Authorization Form
 DCUSA Facility Initiated Transfer Form
 DCUSA Handicapping Labiolingual Index Report
 DCUSA Specialty Care Direct Referral Form
 Delta Dental Member Companies Contact Information
 Designation of Representative Authorization Form
 Direct Deposit/EFT Authorization
 Enrollee Assistance Form (California)
 Enrollee Grievance Form (DDC)
 Enrollee Grievance Form (DDIC)
 Enrollee Grievance Form (DDP Maryland)
 Enrollee Grievance Form (DDP)
 Entity Update Form
 Handicapping Labiolingual Index Report
 HIPAA Authorization Form
 Locum Tenens Provider Form
 Medicare Advantage Attestation
 Non-Covered Services Patient Consent Form
 Notice of Address Change Form
 Notice of Sale of Practice Form
 Online Dentist Directory Form
 Provider Inquiry Form
 Removable Prosthodontics Assessment Form
 TIN Request Form

Delta Dental PPO Resources

Re-credentialing forms

For states not listed, please complete the Enterprise standard credentialing form.