Important Forms for Dentists

Our frequently requested forms help you update your information with us, including your membership participation.

Update your information with us


Address change (PDF, 7 pages, 248kb)
Use this form to update your payment and/or service office address.

Direct deposit (PDF, 3 pages, 100kb)
Direct deposit is available to New Jersey state providers only. If you're a New Jersey state provider, you'll use this form to sign up for direct deposit for claim payment. Dentists outside New Jerseyshould contact their local member company for enrollment across the Delta Dental system.

W-9 (PDF, 7 pages, 235kb)
Use this form to update your TIN information.

Everyday forms


Authorization for Release of Health and Payment Information (PDF, 2 pages, 21kb)
This form authorizes Delta Dental of New Jersey to release protected health information.

Certification of Handicapped Child's Dependency Status (PDF, 1 page, 13kb)
Use this form to certify a dependent is over the contract age limits, but is eligible for benefits due to a handicap.

New Jersey Orthodontic Evaluation HLD (NJ-Mod2) (PDF, 4 pages)
The form provides a mechanism to score an individual’s orthodontic malocclusion to determine medical necessity. This requirement exists for essential health benefit related orthodontic coverage. A minimum score of 26 is required to establish medical necessity.

Integrated Oral Health Option Qualification Form (for diagnoses of diabetes, pregnancy, or heart disease) (PDF, 1 pages, 113kb)
Use this form to document a qualifying medical condition for plans that offer an Integrated Oral Health Benefits option.

Oral Health Enhancement Option Qualification Form (for diagnoses of periodontal disease) (PDF, 1 pages, 16kb)
Use this form to document a qualifying medical condition for plans that offer an enhanced Oral Health Benefits option.

Request for Internal Review (Appeal Form 1A) (PDF, 1 page, 86kb)
Use this form to request an Internal Appeal of a Delta Dental of New Jersey Adverse Claims Determination.

Request for External Review (Appeal Form 1B) (PDF, 1 page, 59kb)
Use this form to request an External Appeal of a Delta Dental of New Jersey Adverse Claims Determination.

Student Documentation Verification (PDF, 1 page, 126kb)
Use this form to certify a dependent child is currently attending an accredited school, college, or university on a full-time basis.