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.

Download Important and Useful Delta Dental Forms

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Authorization for Release of Health and Payment Information (pdf, 2 pages)
This form authorizes Delta Dental of Connecticut to disclose specified health information about the patient listed on the form.

Certification of Handicapped Child's Dependency Status (pdf, 1 page)
This form officially certifies the dependency status of a handicapped child. To be signed by the child's physician.

Claims Form (pdf, 1 page) Lock icon
Use this form to file a claim for services performed in the United States.

Coordination of Benefits (pdf, 1 page)
The coordination of benefits form helps Delta Dental to determine which insurance plan (if not the sole plan) has the primary payment responsibility and the extent to which the other plans will contribute.

Dentist Nomination (pdf, 1 page)
Want your dentist to be a participating Delta Dental dentist? Fill out this form and we'll contact them!

Oral Health Enhancement Option Qualification Form (for diagnoses of periodontal disease) (pdf, 1 page)
If elected by your employer, your dental plan may offer our Oral Health Enhancement Option, which enables eligible enrollees who have been treated for periodontal (gum) disease to receive up to 2 additional cleanings and/or periodontal maintenance procedures per benefit period.

Integrated Oral Health Option Qualification Form (for diagnoses of diabetes, pregnancy, or heart disease) (pdf, 1 page)
If you qualify, the Integrated Oral Health Option enables eligible members who have been diagnosed with certain qualifying conditions to receive up to two additional dental cleanings and/or periodontal maintenance procedures per benefit period beyond the plan’s ordinary limit.

Request for External Review (Appeal Form 1B) (pdf, 1 page)
Use this form for an external appeal review.

Request for Internal Review (Appeal Form 1A) (pdf, 1 page)
Use this form for an internal appeal review.

Student Documentation Verification (PDF, 1 page, 126kb)