Member Forms

Our goal is always to make dental and vision health care as accessible as possible. Our plans are designed based on the latest health science to best meet the health needs of our members and keep your dental and vision costs manageable. 

Our member services help you stay focused on what’s important in your life. We make sure any questions or concerns you have are addressed quickly and clearly. With Delta Dental, we keep you smiling. There’s no hassle in working through claims, saving you time and frustration.

Dental Member Forms 

• Claim Form - Complete if your dentist did not file a claim for your dental treatment
• Authorization Form - Authorization to release personal health information
• Personal Representative Form - If you want another person to represent you when making health care decisions 
• Appeal Form - Information on how to appeal your claim 

Vision Member Forms 

• Claim Form - Use to file out-of-network claim

Individual and Family Coverage  

• Enrollment Application -  Use this form to mail or fax your enrollment in a Delta Dental individual and family plan 

Using Your Benefits

• PPO Plus Premier Network Information - Outlines the benefits of going to a Delta Dental network dentist
• View Your Benefits and More - How to register and use the Delta Dental secure website to view benefits and claims, information on social media, and our mobile app
• Virtual Visits - Information on teledentistry visits and how to access services when your dentist is not available. Learn more on emergency visits.   
• Enhanced Benefits Program - Additional dental benefits based on certain medical conditions (not available on all plans)
• To GoSM - Annual Maximum Carryover - Additional benefit that allows members to carryover unused annual maximums from one year to the next (not available on all plans)
• Check Up Plus - Optional benefit that waives preventive care from annual benefit maximum  (not available on all plans)