Forms for Our Patients and Their Families
Find helpful forms to assist you in utilizing your dental benefits.
Business Forms
- Dependent Verification Request Form
- Enrollment / Change Form – Dental
- Enrollment / Change Form – Vision
- Payment Option Form
Informational Memos
Compliance
- Individual Release of PHI Authorization
- HIPAA Privacy Notice
- Privacy Complaint Form
- Martin's Point Generations Advantage Patients
Forms for Our Employers and Groups
Use these helpful forms and materials to assist you in administering Northeast Delta Dental benefit plans.
Authorization Letters
Business Forms
- Dependent Verification Request
- Employee Enrollment / Change Form - (Dental)
- Employee Enrollment / Change Form - (Vision)
- GOSE Refund Request Form
- Group Supplies Order Form
- Payment Option Form - Fully Insured and Vision
- Payment Option Form - Monthly Billed ASO
- Payment Option Form - Weekly Billed ASO
- Termination Report Form
Informational Materials
Compliance
Forms for Our Providers and Their Office Staff
Find the helpful forms and materials to assist you with processing Northeast Delta Dental claims and much more.
For dentists who are newly applying to join our networks or participating dentists who are adding an office location, please contact Provider Services at 1-800-537-1715 extension 1100. Provider Services will email you the necessary paperwork.
Business Forms
- Web Benefit Instructions for Dental Offices
- W-9 Form
- Northeast Delta Dental Re-Credentialing Application
Compliance
- Individual Release of PHI Authorization
- HIPAA Privacy Notice
- Martin's Point Generations Advantage Patients
- Medically Necessary Orthodontic Forms
Forms for Our Producers and Consultants
Find the helpful forms and materials to assist you with marketing Northeast Delta Dental Products and Services.
Authorization Letters
Business Forms
- Termination Report Form
- Employee Enrollment / Change Form - (Dental)
- Employee Enrollment / Change Form - (Vision)
- Producer Supplies Order Form