Download Important and Useful Delta Dental Forms

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

Disabled Dependent Verification Certification (pdf, 1 page)
This form officially certifies the dependency status of a disabled dependent. To be signed by the child's physician.

Claim Form (pdf, 1 page) 
Use this form to file a claim for services performed in the United States. Please mail your claim form to:

Delta Dental of New Jersey
P.O. Box 16354
Little Rock, AR 72231

Coordination of Benefits (pdf, 1 page)
The coordination of benefits form helps Delta Dental to determine which 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. Appeals should be mailed to:

Delta Dental of New Jersey
P.O. Box 15132
Little Rock, AR 72231

Request for Internal Review (Appeal Form 1A) (pdf, 1 page)
Use this form for an internal appeal review. Appeals should be mailed to:

Delta Dental of New Jersey
P.O. Box 15132
Little Rock, AR 72231

Treating Dentist Attestation (pdf, 1 page)
Attestation must be accompanied by a claim form and a manufacturer receipt.

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