Notice
Change Healthcare announced a breach of HIPAA privacy and is reaching out to individuals whose personal information may have been compromised. Although this incident does not involve Delta Dental of New Jersey or Connecticut, Change Healthcare is a vendor we used and we are providing this information to help our members who might be affected.
Dental Forms for Brokers
Find a variety of helpful forms or applications to keep your client’s information updated.
Small group forms for brokers
Small Business Program Group Dental and Vision Application (PDF, 9 pages, 1,930 KB)
Delta Dental CT Enrollment Template (Excel Spreadsheet)
Enrollment/Change Form (Dental and Vision) (PDF, 1 page, 204kb)
Individual Commissions Forms
Producer Appointment Forms (pdf, 26 pages, 789KB)
Standard Forms for Brokers
Authorization Form Granting Access to PHI - Insured Clients (PDF, 3 pages, 52kb)
Authorization Form Granting Access to PHI - Self Funded Clients (PDF, 3 pages, 51kb)
Learn more
Individual Commissions Forms
Get started on becoming an individual and family plan broker
View forms
Delta Dental of Connecticut is a part of Delta Dental Plans Association. Through our national network of Delta Dental companies, we offer dental coverage in all 50 states, Puerto Rico and other U.S. territories.
