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.
Holiday Hours
Happy Holidays! We are looking forward to a healthy, smile-filled 2025.
Customer Service holiday hours
Important Forms for Dentists
Our frequently requested forms are all here
Update your information with us
Address change (PDF, 1 page, 63kb)
Use this form to update your payment and/or service office address.
W-9 (PDF, 7 pages, 235kb)
Use this form to report your TIN information.
Everyday forms
Authorization for Release of Health and Payment Information (PDF, 2 pages, 21kb)
This form authorizes Delta Dental of Connecticut 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 Connecticut 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 Connecticut 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.
Treating Dentist Attestation (PDF, 1 page)
Attestation must be accompanied by a claim form and a manufacturer receipt.
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.
