Update your information, or join a new network, using our online forms
Need help? Use our form wizard. You will need the latest version of Google Chrome or Microsoft Edge to access these forms. If you have credentialing questions, reach out to ProviderServices@DeltaDentalWA.com, or call 1-800-238-3439.
Become a Member Dentist
If you’re interested in becoming a Member Dentist, we make the process easy. Simply follow these steps to join our Delta Dental Premier network. You can also choose within this packet to join the Delta Dental PPO network at the same time.
Add a Practice/Location to your Delta Dental Membership
If you're already a Delta Dental Member Dentist, and are adding an additional location to your membership, follow these steps:
Non-Participating Provider Application
Use this form if you're not a participating provider with us and have submitted a claim. We'll use your information to update our records and process the claim accordingly. You may also need this form if you're a Denturist, Hygienist, Physician or Anesthesiologist.
Update your information with us
Address change form
Use this form to update your payment and/or service office address.
Member Dentists are required to be re-credentialed every 3 years. We’ll notify you when it’s time to complete and return this packet.
- Tax Id number change notification
Use this form to notify us of a TIN change.
Specialty Change Form
Use this form if you are changing from one specialty to another.
Termination request form
We require written notification when you close a service office, or terminate your network membership. Submit this form if you're: closing a service office, terminating network membership/participation, retiring, leaving a specific location, opening your own practice or moving out of state.The form will be submitted to us securely, through DocuSign.
Direct deposit form
Direct deposit is available to Washington state providers only. If you're a Washington state provider, you'll use this form to sign up for direct deposit for claim payment. For instructions on how to complete this form, click here. We require all offices that operate under the same TIN to be reimbursed using the same method. If you signup for direct deposit, the same direct deposit information will be used for all providers with the TIN. Click here to learn more.