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Get Delta Dental Member Self-Report Form

to Delta Dental, will enable you to take advantage of extra dental and/or periodontal cleanings (up to a total of 4 annually), covered as preventive care, when you have certain medical conditions. Please indicate below which of the following medical condition you are experiencing. Check all that apply. Note: If you have already received periodontal therapy and claims for those services are on file with Delta Dental, you do not need to file a self-report form. Your benefits have already been upd.

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