Forms to Manage Your Delta Dental Benefits

Member Forms 

• Dental Claim Form - Complete if your dentist did not file a claim for your dental treatment
• Vision Claim Form - Use to file out-of-network vision claims
• Authorization Form - Authorization to release personal health information
• Personal Representative Form - Allows individual to appoint another person to represent them when making health care decisions
• Appeal Form - Information on how to appeal a Delta Dental claim

Small Group (1 to 50 employees) Enrollment Documents

• Employer Choice Enrollment/Change Application (member document)
• Employee Choice Enrollment/Change Application (member document)
• Pre-ACA Voluntary Enrollment/Change Application (member document) 
• DeltaVision Member Enrollment/Change Form (member document)
• Dental and Vision Member Enrollment/Change (member document)

Large Group (51+ employees) Enrollment Documents

• Member Enrollment/Change Application (member document)
• Large Group Employee Choice Enrollment/Change Application (member document) 
• DeltaVision Member Enrollment/Change Form (member document)
• Dental and Vision Member Enrollment/Change Form (member document)

Employer Forms and Documents

• Notice of Financial Privacy Practices
• Small Group Guide for Administering Your Dental Benefit Plan (1 to 50 employees) 
• Large Group Guide for Administering Your Dental Benefit Plan (51+ employees)
• ACH Form (fully-insured) - Form to have premium electronically withdrawn
• ACH Form (self-insured weekly) - Form to have weekly payment withdrawn