Notify the Plan of other insurance coverage in order to determine the order of benefits/coverage. You can also submit this form by logging in to your Benefits Manager, clicking on 'Go Paperless' from the menu and selecting 'Forms and Letters.'
Submit medical care claims to the Plan.
Submit dental care claims if you are treated by a dentist who is not a member of Delta Dental. See instructions on how to submit this form.
Get reimbursed for prescription drug claims. Please use the Medical Claim Form if you are submitting prescription receipts under secondary coverage.
Submit this form for mental health/substance abuse treatment claims.
Health care providers can submit this form for services provided to patients.