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Dental Forms

    General Claims and Disability Forms

    Dental Claims
  • Dental Claim Form – Use this form to submit a claim to Delta Dental.
  • IMPORTANT! The packets below describes the benefits provided under the DeltaCare USA Dental HMO Plan. Enrollment is time sensitive. For your convenience, an enrollment form is included in this packet as well as a provider directory. If you would like to enroll in the DHMO plan, please complete the enrollment form and return it to the Fund Office within 30 days of the commencement of your coverage.
  • DeltaCare USA Evidence of Coverage – This booklet provides the benefits for the DeltaCareUSA HMO plan, please read it carefully before choosing the DeltaCareUSA plan.
  • DeltaCare USA Election Packet Southern California
  • DeltaCare USA Election Packet Northern California
  • IMPORTANT: Each packet is 40 to 80 pages in length. Please be sure you view the information before printing. Only the enrollment form (page 1) needs to be returned to the Fund Office.