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If you have a question regarding a claim or patient's eligibility please take a moment to complete the requested information. It will help our Customer Service representative respond quickly and accurately.
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= Required Fields
1. Please complete the following:
Dentist/Dental Office Name:
*
2. Please complete the below information to verify claim payment, and/or coverage limitations.
Subscriber ID number:
-
-
###-##-#### (This is a nine digit number
located under the members' name on the
Delta Dental ID card.) Please note, in order
to protect our member’s privacy, as of June
2007 we no longer use Social Security
Number as a Subscriber ID.
Name of member who received care:
Date of Service:
Calendar
Today
Group Number:
Subscriber's Name:
Employer's Name:
Birth Date:
Calendar
Today
3. Please briefly explain your request.
4.
Your telephone number:
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5.
Your E-mail Address:
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