Dental and Vision Forms

Delta Dental of Iowa offers you and your clients a variety of resources. Below are some common forms that you and your clients may need to access. 

• Delta Dental Small Group Materials 
• Delta Dental Large Group Materials
• Delta Dental Individual and Family Plan Materials
• DeltaVision Materials
• Other Forms, Documents and Resources for Agents, Groups and Members  

Delta Dental Small Group Forms (1 to 50 employees) 

• Employer Choice Plan Member Enrollment Application (member document)
• Employee Choice Plan Enrollment Application (member document) 
• Pre-ACA Voluntary Member Enrollment Application (member document)
• Small Business All Product Application (NEW group document to enroll in plans)
• 2024 Small Group Materials (all small group plans for 2023)

Delta Dental Large Group Forms (51+ employees)

• Large Group Member Enrollment Application (member document)
• Large Group Employee Choice Enrollment Application - Platinum, Preferred, Preventive (member document) 
• Large Group Voluntary Enrollment Application - Comprehensive, Catastrophic, Preventive (member document)
• Large Group All Product Application (NEW group document to enroll in plans)
• Large Group Employee Choice Plan - Platinum, Preferred, Preventive (member document)

Delta Dental Individual and Family Plans 

Information on benefits, rates, and brochure for Delta Dental's individual product for retirees, self-employed, students or Iowans that do not have group dental benefits. 

• 2024 Individual Dental and Vision Plan Brochure
• Individual Agent Application
• Agency Provisions for Marketing Individual Delta Dental Products

DeltaVision^® Forms and Brochures

Vision care plans that combine choice, value and wellness from a name you trust - Delta Dental.

• DeltaVision Custom Group Brochure (501+ employees) 
• DeltaVision Standard Group Flyer (1 to 500 employees 4-tier rates)
• 2024 DeltaVision Individual and Family Flyer

DeltaVision Forms and Applications 

• Small Business All Product Application (NEW group document)
• Large Group All Product Application (NEW group document)
• DeltaVision Small or Large Group Member Enrollment/Change Form (member document)
• Dental and Vision Large Group Member Enrollment/Change Form (member document)
• Dental and Vision Small Group Member Enrollment/Change (member document)
• Individual Agent Application

Vision Member Forms 

• Claim Form - Use to file out-of-network claims

Agent Forms 

• Requesting Proposal - Guidelines for requesting quotes for employer groups with 51 or more eligible employees.  

Dental Member Forms and Information

• Dental Claim Form - Complete if your dentist did not file a claim for your dental treatment
• Authorization Form - Authorization to release personal health information
• Personal Representative Form - If you want another person to represent you when making health care decisions 
• Appeal Form - Information on how to appeal your claim 
• Virtual Visits - Information on teledentistry visits and how to access services when your dentist is not available. Learn more on emergency visits.