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On October 10, we will be upgrading our phone system. This enhancement will improve your future experience. It may result in additional wait times during our transition. We appreciate your understanding and patience as we work to serve you better.

On October 10, our call center will be closed for staff training between 12 PM and 1 PM ET.
On October 9, due to the enhancement to our phone system, our IVR will be unavailable for self-service from 6.30 PM through 11:59 PM ET.

Important forms for Dentists

Our frequently requested forms are all here

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) Lock icon
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.