Forms

Become a Member Dentist

Thank you for your interest in becoming a Washington Member Dentist and joining the Delta Dental network.

To contract with Delta Dental and join our Premier network, follow the steps below. You may also choose to join our PPO network within your application:

1. Review the Member Dentist Rules and Regulations to learn more about contracting as a Member Dentist with Delta Dental of Washington

2. Complete the application and submit required documentation (Washington providers only)

3. Expect to hear back from us within 18-21 business days after submitting your completed application

Add a Washington practice or location to your Delta Dental membership

If you're already a Delta Dental of Washington Member Dentist and want to contract at an additional location, follow the steps below.

1. Review the Member Dentist Rules and Regulations to refresh on contracting as a Member Dentist with Delta Dental of Washington

2. Complete the application and submit required documentation

3. Expect to hear back from us within 18-21 business days after submitting your completed application

Recredentialing application

Washington Member Dentists are required to be recredentialed every 3 years. You’ll receive an email notification before your due date and a confirmation once your completed application is processed.

Important: Recredentialing applications are for Washington State Member Dentists only.

Recredentialing packet

Online Fillable Form

Non-Participating Provider Application

Use this form if you are a Washington Denturist, Hygienist, Physician, or Anesthesiologist and wish to become non-participating (out-of-network) provider to submit claims. We'll process and update our records with your information within 7-10 business days of receiving your completed application.

Complete the Non-Participating Provider Application

Online Fillable Form

Address change form

Use this form to change your payment and/or service office address(es). We’ll process your address change(s) within 7-10 business days of receiving your completed form.

Tax ID Number (TIN) change notification

Use this form to notify us of a TIN change. We’ll process your completed notification within 7-10 business days.

Specialty change request form

Use this form if you are changing from one specialty to another. We’ll process your completed request within 18-21 business days.

Termination request form

To fulfill your requirement of providing written notice if leaving a location or terminating an aspect of your membership, submit this form if you're: closing a service office, terminating network membership/participation, retiring, leaving a specific location, or moving out of state.

We'll review your completed request within 7-10 days (note: the effective date is dependent on contractual obligations).

Direct deposit form (available to Washington State providers only)

If you're a Washington State dentist, use this form to sign up for direct deposit and Electronic Remittance Advice (ERA) for claims payment from DDWA and Out of State Delta Dentals. For instructions on how to complete this form, click here. We’ll process your completed request within 7-10 business days.

Note: We require all offices that operate under the same TIN to be reimbursed using the same method. If you sign up for direct deposit, the same direct deposit information will be used for all providers with the TIN. Click here to learn more.

W-9 form

Use this form to report your TIN information or to change the address on file for the yearly sending of 1099 statements. We’ll process your completed request within 7-10 business days.

ADA Form

Use this standard form from the American Dental Association (ADA) for reporting dental services to a patient's dental benefit plan. For instructions on completing this form, visit the ADA website.

Claims forms

Locate, complete, and submit the claim form that meets your needs.

Orthodontic medical necessity form

Complete this form when a group requires a preauthorization to determine the medical necessity of orthodontic treatment (Class 22).

Time Limitation Exception Form

Most dental procedures covered by our plans include a time limitation to allow benefit payment. For example, tooth surfaces treated with a direct restoration are generally covered once every two years.

Use this form only when requesting review of a dental procedure previously adjudicated as not billable to the patient due to a time limitation policy, and when extenuating clinical circumstances exist (i.e, this form is not to be used for standard claim submissions).

All claims remain subject to group filing requirements and will not be reviewed or reprocessed beyond a group’s filing period. Exceptions to our clinical criteria will also not be considered to allow benefit.

Additional payment with regard to contract time and frequency limitations will not be considered, and an approved exception may only change a claim adjudication from “not billable” to “patient responsibility” pending review.

Email completed Time Limitation Exception Forms to ClinicalReviewProcessing@DeltaDentalWA.com.

DeltaCare® Dentist Status Change Form

After you've connected with a Provider Ambassador about your DeltaCare® status, use this form to update if your practice is currently open or closed to accept new DeltaCare® patients as their Primary Care Dentist (PCD). We’ll process your status change and notify you within 7-10 business days of receiving your completed form.

DeltaCare® Specialty Referral Form

Use this form to refer your patient to a specialist. (Note: you don’t have to complete this form for orthodontic referrals).

Adult - Optional Treatment Consent Form

Use this form when a patient elects to receive optional treatment.

Pediatric - Optional Treatment Consent Form

Use this form when a parent or guardian elects an optional treatment for their child.

About DeltaCare

DeltaCare is Delta Dental of Washington’s managed care plan. Patients choose their Primary Care Dentist (PCD), who serves as DeltaCare patients primary oral healthcare provider and can also refer those patients to participating DeltaCare Specialists when needed. For questions on DeltaCare, email Provider@DeltaDentalWA.com.