If you choose to go out-of-network for your dental care, you may be reimbursed for your treatment. Complete the patient and subscriber information on the Delta Dental Claims Form.
Mail the completed form and a copy of the dentist’s Statement of Treatment (or detailed receipt) to:
Delta Dental Insurance Company
PO Box 1809
Alpharetta, GA 30023
The Statement of Treatment or detailed receipt must include:
- Name, address, and complete phone number of dentist
- Date each service was performed
- Description, procedure code, and fee of each service performed
- List of affected teeth
- Total cost of services performed
- Dentist’s National Provider Identifier (NPI)
- Dentist’s Tax Identification Number (TIN)
- State license number
- Specialty code
Important note: If the Statement of Treatment or similar document you receive from your dentist is missing any of the information listed above, please enter it on the claim form. A dental office staff member can provide you with the dentist and treatment information.
Be sure to make a copy of the completed claim form and the dentist’s Statement of Treatment or detailed receipt for your records.