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  • Delta Dental Claim Form Roanoke

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AME 2. RELATIONSHIP TO SUBSCRIBER SELF 6. SUBSCRIBER FNAME SPOUSE MI CHILD OTHER LNAME 3. SEX M 4. PATIENT BIRTHDATE F MO. DAY YEAR 7. SUBSCRIBER IDENTIFICATION NO 5. IF CHILD AGE 19 OR OVER: FULL TIME STUDENT: NO YES NAME OF SCHOOL 8. NAME OF EMPLOYER 9. GROUP NUMBER 10. SUBSCRIBER MAILING ADDRESS 11. CITY, STATE, ZIP 12. IS PATIENT COVERED BY ANOTHER DENTAL PLAN? NO YES 14. SUBSCRIBER ID NO. 13. EMPLOYEE NAME AND BIRTHDATE 15. EMPLOYER NAME 16. NAME AND ADDRESS OF C.

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Related links form

PR Modelo SC 2909 A 2018 DE Bezirksregierung Dusseldorf Antrag Auf Zuerkennung Der Vollen Fachhochschulreife 2023 KY KREC Form 200 2019 TX Affidavit For Removal Of Property Of Deceased Incarcerated Or Permanently Incapacitated Tenant 2005

Questions & Answers

Get answers to your most pressing questions about US Legal Forms API.

Contact support

Call our customer service team at 800-524-0149 for member eligibility, benefits information and claims inquiries. Or, you may call DASI 24/7 at 800-462-7283 to check the status of claims, including those submitted electronically.

You can also cancel your policy online or over the phone. "In Network Dentist Benefits." Delta PPO Dental (Group # 2999-0011) Contact Information: 1-800-765-6003 https://www1.deltadentalins.com/ Delta Dental PPO: You should pay your dentist directly for the care you receive.

If you prefer to write Delta Dental with your question(s), you can do so via email to customer.care@deltadentalma.com or by mail: 465 Medford Street, Boston MA 02129.

DeltaCare USA's payer identification number for encounter forms is DDCA3.

The California Department of Managed Health Care is responsible for regulating health care service plans.

Appeals should be sent to: Delta Dental of New Jersey, P.O. Box 15132, Little Rock, AR 72231. Claim submissions for members of our individual plan should still go to Delta Dental of New Jersey, P.O. Box 103, Stevens Point, WI 54481.

And that means road trips and vacations. While we don't like to think about it, dental emergencies can happen anywhere – even while on vacation. Fortunately, most Delta Dental plans work anywhere in the United States.

You can file a grievance by doing one of the following: Call toll-free at 1-866-864-2499. Send a fax to 1-833-866-4650.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
Content Takedown Policy
Bug Bounty Program
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
+1 833 426 79 33
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232