Notice

As COVID-19 continues to spread both nationally and locally, the health of our associates is our top priority. Effective Monday, March 23, 2020, and until further notice, our physical office and call center are closed, and the majority of our associates are working remotely. Learn more about how we’re continuing to serve our customers during this time.

Important Forms for Dentists

Our frequently requested forms are all here

Update your information with us

Address change (PDF, 7 pages, 248kb)
Use this form to update your payment and/or service office address.

Direct Deposit (PDF, 3 pages, 100kb)
Direct deposit is available to Connecticut state providers only. If you're a Connecticut state provider, you'll use this form to sign up for direct deposit for claim payment.

W-9 (PDF, 7 pages, 235kb)
Use this form to report your TIN information.

Everyday forms

Authorization for Release of Health and Payment Information(PDF, 2 pages, 21kb)
This form authorizes Delta Dental of Connecticut to release protected health information.

Certification of Handicapped Child's Dependency Status  (PDF, 1 page, 13kb)
Use this form to certify a dependent is over the contract age limits, but is eligible for benefits due to a disability.

Integrated Oral Health Option Qualification Form (for diagnoses of diabetes, pregnancy, or heart disease) (PDF, 1 pages, 113kb)
Use this form to document a qualifying medical condition for plans that offer an Integrated Oral Health Benefits option.

Oral Health Enhancement Option Qualification Form (for diagnoses of periodontal disease) (PDF, 1 pages, 16kb)
Use this form to document a qualifying medical condition for plans that offer an enhanced Oral Health Benefits option.

Request for External Review (Appeal Form 1B) (PDF, 1 page, 59kb)
Use this form to request an External Appeal of a Delta Dental of Connecticut Adverse Claims Determination.

Request for Internal Review (Appeal Form 1A)  (PDF, 1 page, 86kb)
Use this form to request an Internal Appeal of a Delta Dental of Connecticut Adverse Claims Determination.

Student Documentation Verification  (PDF, 1 page, 126kb)
Use this form to certify a dependent child is currently attending an accredited school, college, or university on a full-time basis.