Provider Forms
Download our most used provider forms.
ADA Dental Claim Form – sign in to download form
Use this form for standard dental claims.
Use this form for standard dental claims.
HLD (NJ Mod2) Index: Orthodontic Evaluation Form
Required for NJ and CT claims
Use this form to evaluate the conditions that may or may not qualify patients for coverage of medically necessary orthodontic services.
Required for NJ and CT claims
Use this form to evaluate the conditions that may or may not qualify patients for coverage of medically necessary orthodontic services.
Bridge/Implant Claim Additional Information Form
Use this form to submit additional information when determining bridge and/or implant treatment benefits.
Use this form to submit additional information when determining bridge and/or implant treatment benefits.
Salzmann Index: Orthodontic Evaluation Form
Required for IL, VA, and WI claims
Use this form to evaluate the conditions that may or may not qualify patients for coverage of medically necessary orthodontic services.
Required for IL, VA, and WI claims
Use this form to evaluate the conditions that may or may not qualify patients for coverage of medically necessary orthodontic services.
Washington Health Benefit Exchange Policy: Orthodontic HLD Evaluation Form
Required for Washington Health Benefit Exchange claims
Use this form to evaluate the conditions that may or may not qualify patients for coverage of medically necessary orthodontic services.
Required for Washington Health Benefit Exchange claims
Use this form to evaluate the conditions that may or may not qualify patients for coverage of medically necessary orthodontic services.
For credentialing, contact your local Delta Dental company to learn more.
