Forms
Update your information, or join a new network, using our online forms
Become a Member Dentist
If you’re interested in becoming a Member Dentist, we make the process easy. Simply follow these steps to join our Delta Dental Premier network. You can also choose within this packet to join the Delta Dental PPO network at the same time.
Add a Practice/Location to your Delta Dental Membership
If you're already a Delta Dental Member Dentist, and are adding an additional location to your membership, follow these steps:
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
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Address change form
Use this form to update your payment and/or service office address. -
Re-credentialing packet
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. - Tax Id number change notification
Use this form to notify us of a TIN change. -
Specialty Change Form
Use this form if you are changing from one specialty to another. -
Termination request form
We require written notification when you close a service office, or terminate your network membership. Submit 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.The form will be submitted to us securely, through DocuSign. -
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.
Other forms
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Delta Dental Claims Forms
Get your claim started by submitting one of the standard forms that relates to your needs. -
Request Individual & Family Plan QR Tent Cards
To give your patients information about dental plans for individuals with Delta Dental, we have DDWA tent cards available to display at your reception desk. These cards include a QR code that allow your patients to easily view the whole array of plans for individuals and learn more about each of our unique plans. -
Orthodontic medical necessity form
Use this form when orthodontic treatment is considered medically necessary. -
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. -
W-9 form
Use this form to report your TIN information.
DeltaCare forms
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Dentist Status Change Form
Use this form to update the status of your practice as a DeltaCare provider. -
DeltaCare Specialty Referral Form
Use this form to refer your patient to a specialist. This form is not needed for orthodontic referrals. -
Optional Treatment Consent Form
Use this form if your patient elects to have optional treatment completed. - Optional Treatment Consent Form – Pediatric
Use this form if your patient elects to have optional treatment completed. -
DeltaCare Facility Audit Form
Use this form when you're a new DeltaCare provider or have moved to a new location.
