Get the free Delta Dental Claim Form - myBenefitEssentials

Delta Dental of Pennsylvania ATTENDING DENTIST S STATEMENT P.O. Box 2105 Mechanicsburg, PA 17055-6999 (717) 766-8500 (800) 932-0783 TTY/TDD 888-373-3582 www.deltadentalins.com SIGN BELOW FOR PREDETERMINATION

How to fill out delta dental claim form

How to fill out a Delta Dental claim form:

1. Obtain the claim form: Start by obtaining the Delta Dental claim form. You can usually find it on the Delta Dental website or request a physical copy from your dental insurance provider.
2. Provide personal information: Fill in your personal information on the claim form. This typically includes your name, address, date of birth, and social security number. Make sure to double-check the accuracy of this information.
3. Include policy information: Enter your dental insurance policy information on the claim form. This includes your policy number, group number, and any other relevant identification numbers provided by your insurance company.
4. Indicate patient information: Next, provide the patient's information if different from your own. Include the patient's name, relationship to the policyholder (if applicable), and date of birth.
5. Specify the provider details: Fill out the section that requests information about the dental provider who performed the services. Include the name, address, and contact information of the dental office or dentist.
6. Provide treatment details: This is perhaps the most crucial part of the claim form. Write down the date of service, the specific dental procedures performed, and any associated diagnosis codes or tooth numbers that apply. Make sure to include all relevant details accurately.
7. Include supporting documents: If there are any supporting documents related to your claim, such as dental charts, X-rays, or receipts, ensure that you attach copies to the claim form. These documents can help expedite the processing of your claim.
8. Review and sign the form: Carefully review all the filled-out sections of the claim form to ensure accuracy and completeness. Once you are confident that everything is correct, sign and date the form to authorize the submission.

Who needs a Delta Dental claim form?

A Delta Dental claim form is needed by individuals who have dental insurance coverage through Delta Dental or a Delta Dental affiliate. If you have received dental treatment and wish to be reimbursed for the eligible expenses covered by your insurance plan, you will need to fill out and submit a Delta Dental claim form. This form is typically required by Delta Dental or your dental insurance provider to process and evaluate your claim for payment.

For pdfFiller’s FAQs

What is delta dental claim form?

Delta Dental claim form is a document used by dental patients to request reimbursement for dental services from Delta Dental, a dental insurance company.

Who is required to file delta dental claim form?

Any dental patient who is covered by Delta Dental insurance and wishes to seek reimbursement for dental services is required to file a delta dental claim form.

How to fill out delta dental claim form?

To fill out a delta dental claim form, the patient needs to provide their personal information, dentist's details, details of the dental services received, and attach any necessary supporting documents such as invoices or receipts. The completed form can be submitted online or through mail, as per Delta Dental's instructions.

What is the purpose of delta dental claim form?

The purpose of the delta dental claim form is to allow dental patients to request reimbursement for the dental services they have received from Delta Dental insurance.

What information must be reported on delta dental claim form?

The delta dental claim form typically requires the patient to report their personal information, insurance details, dentist's information, details of the dental services received, treatment dates, codes for procedures, and any supporting documentation.

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