Delta Dental Claims Forms
Get your claim started by submitting one of the standard forms that relates to your needs.
- Coordination of Benefits Questionnaire
Use this form when coordinating dental benefits with another dental coverage provider (e.g., your spouse's coverage). - Subscriber Appeals Form
Use this form to file an appeal of an adverse benefit determination. - Out of the Country Claim Form
Use this form to file a claim for services performed outside the United States. - Authorized Representative Form for Appeals
Use this form when you have chosen a representative to assist with your appeal. This will allow Delta Dental of Washington to release relevant information to the chosen party. - Standard Claim 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 - HIPAA Authorization Form
Use this form to view overage dependents information or if you're having custody issues.
