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.
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. If you have any questions, email 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.