Notice:
Our office will be closed at noon on May 29 and all day on Friday, May 30 for annual training. You can access benefit, eligibility, and claim information at deltadentalwa.com or through our Interactive Voice Response system. We’ll be back during regular business hours on Monday, June 2. Thank you for your understanding.
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.
