Follow the steps to complete the form successfully.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by selecting the type of transaction applicable to your situation by checking the appropriate boxes: Statement of Actual Services or Request for Predetermination/Preauthorization.
3. Fill in the carrier name and address with 'Delta Dental of Illinois, P.O. Box 5402, Lisle, IL 60532'. Ensure you do not use this form for DeltaCare dental HMO.
4. Provide the primary payer information including the name, address, city, state, and zip code of the subscriber. Indicate whether there is other dental or medical coverage by selecting 'Yes' or 'No'.
5. If there is other coverage, complete the subscriber's details by filling in their name, date of birth, gender, subscriber identifier, and employer name.
6. Enter patient information, including their relationship to the primary subscriber, student status, and personal details such as name, date of birth, and gender.
7. Fill out the record of services provided. This section requires you to enter the procedure date, areas of the oral cavity involved, the teeth affected, procedure codes, and the fees associated with each service.
8. If applicable, document any missing teeth by placing an 'X' on the provided chart indicating which teeth are missing.
9. Complete the diagnosis information by providing diagnosis codes and any additional remarks as necessary.
10. In the authorizations section, review the agreements and sign where indicated, providing the signature and date of both the patient/guardian and subscriber.
11. If dental treatment was for orthodontics, provide the required details about the treatment duration and appliance placement dates.
12. Conclude by filling in any additional information regarding the treating dentist, including their details and certification of completed procedures.
13. Review all provided information for accuracy before moving to save, download, print, or share the completed form.

Start completing your IL Delta Dental 4521 form online today for seamless dental benefit processing.