Important forms for Dentists

Update your information with us

Address change (PDF, 1 page, 64kb)
Use this form to update your payment and/or service office address.

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

Everyday forms

Claim Form (pdf, 1 page) 
Use this form to file a claim for services performed in the United States. Please mail your claim form to:

Delta Dental of New Jersey
P.O. Box 16354
Little Rock, AR 72231

Treating Dentist Attestation (pdf, 1 page)
Attestation must be accompanied by a claim form and a manufacturer receipt.

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.

Disabled Dependent Verification Certification (PDF, 1 page, 13kb)
This form officially certifies the dependency status of a disabled dependent. To be signed by the child's physician.

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)
If you qualify, the Integrated Oral Health Option enables eligible members who have been diagnosed with certain qualifying conditions to receive up to two additional dental cleanings and/or periodontal maintenance procedures per benefit period beyond the plan’s ordinary limit. 

Oral Health Enhancement Option Qualification Form (for diagnoses of periodontal disease) (PDF, 1 pages, 16kb)
If elected by your employer, your dental plan may offer our Oral Health Enhancement Option, which enables eligible enrollees who have been treated for periodontal (gum) disease to receive up to 2 additional cleanings and/or periodontal maintenance procedures per benefit period. 

Request for Internal Review (Appeal Form 1A) (PDF, 1 page, 44kb)
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, 45kb)
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.