Our frequently requested forms help you update your information with us, including your membership participation. You'll be able to fill out the forms online and submit them to us directly.
New Member Dentist application
Use this form if you're interested in becoming a member dentist with Delta Dental of Washington. This process will take approximately 4-6 weeks and changes to any current membership will be made using a future date only. To view Member Dentist Rules and Regulations, click here. If you've purchased a practice, you'll also need to include a Transfer of practice ownership form.
Adding a location Member Dentist application
Use this form if you're already a Delta Dental member dentist and are adding an additional location. If you've purchased a practice, you'll also need to include a Transfer of practice ownership form.
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. Please email the completed packet to ProviderCredentialing@DeltaDentalWA.com.
- Tax Id number change notification
Use this form to notify us of a TIN change.
Termination request form
Delta Dental requires written notification when you close a service office or terminate your network membership. You'll use 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.
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.
Electronic Remittance Advice (ERA)
Once you've enrolled in direct deposit, you can receive your remittance advice electronically. For additional information and/or to enroll, please select the link below for the clearing house you currently use to submit claims. You're able to submit claims using more than one clearing house; however, you must only select one clearinghouse to receive your ERA.
Emdeon - Follow the ERA instructions for Delta Dental of Washington
DentalXChange - Click on the view payers that require enrollment button and follow the ERA instructions for Delta Dental of Washington.
TESIA Clearinghouse - On the right hand side, fill out the information requested under 'Request ERA Enrollment Materials.' You can also contact TESIA Clearinghouse directly at 1-800-724-7420, option 5.