Important Forms for Dentists

Update your information with us

Address change (PDF, 1 page, 63kb)
Use this form to update your payment and/or service office address.

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.

New Jersey Orthodontic Evaluation HLD (NJ-Mod2) (PDF, 4 pages)
The form provides a mechanism to score an individual’s orthodontic malocclusion to determine medical necessity. This requirement exists for essential health benefit related orthodontic coverage. A minimum score of 26 is required to establish medical necessity.

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.