Notice
Monday, January 20: Our Customer Service line (800-452-9310) will be closed in observance of Martin Luther King Jr. Day. Accounts with dedicated customer service numbers can still call between 9:00 AM and 5:00 PM ET, but may experience longer wait times. We apologize for any inconvenience this may cause.
Need benefit information and claim status in a hurry? The MySmile self-service website and Interactive Voice Response system (800-452-9310) are available 24/7.
Change Healthcare announced a breach of HIPAA privacy and is reaching out to individuals whose personal information may have been compromised. Although this incident does not involve Delta Dental of New Jersey or Connecticut, Change Healthcare is a vendor we used and we are providing this information to help our members who might be affected.
Download Important and Useful Delta Dental Forms
Get the forms you need
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)
Delta Dental of New Jersey is a part of Delta Dental Plans Association. Through our national network of Delta Dental companies, we offer dental coverage in all 50 states, Puerto Rico and other U.S. territories.
