Delta Dental of Arizona

SCHEDULED MAINTENANCE: We will be performing system maintenance 8 p.m. Saturday, July 27 through 3 a.m. Sunday, July 28. During this time, certain website features like the cost estimator or dentist search may be unavailable. We apologize for any inconvenience.

Forms Library

Browse our library of forms for Delta Dental of Arizona members, group administrators, brokers and dentists. Additional forms may be available by signing in to your portal account. If you still can't find what you're looking for, please feel free to contact us.

Member Forms

Appeals & Grievances

Online Fillable Form

EFT Authorization: Direct Billing Members

Online Fillable Form

Enrollment/Change of Status Form

Downloadable Form

Solicitud de Inscripción/Modificación

Downloadable Form

HIPAA Release - Group Plan Members (English/Spanish)

Downloadable Form

HIPAA Release - Individual Plan Members (English/Spanish)

Downloadable Form

ACH Authorization: Groups/Employers

Online Fillable Form

Appeals & Grievances

Online Fillable Form

Enrollment/Change of Status Form

Downloadable Form

Solicitud de Inscripción/Modificación

Downloadable Form

Generic Enrollment Spreadsheet - Dental/Vision

Downloadable Form

Group Enrollment File Upload Tool

Online Fillable Form

HIPAA Release - Group Plan Members (English/Spanish)

Downloadable Form

Request/Change BMT Administrator

Online Fillable Form

Secure Document Upload Tool

Online Fillable Form

Broker Appointment Application

Online Fillable Form

Direct Deposit for Brokers

Online Fillable Form

Request For Proposal

Online Fillable Form

Request Individual Plan Broker URL

Online Fillable Form

Individual & Family Enrollment Application

Downloadable Form

Enrollment Kit: 2-9 Enrolled Employees

Downloadable Form

Enrollment Kit: 10+ Enrolled Employees

Downloadable Form

Enrollment/Change of Status Form

Downloadable Form

Generic Enrollment Spreadsheet - Dental/Vision

Downloadable Form

Appeals & Grievances

Online Fillable Form

DEA Registration Waiver

Downloadable Form

Dental Office Profile Update

Online Fillable Form

Join Network

Online Fillable Form

Medicare Advantage Compliance Attestation

Downloadable Form

Medicare Advantage Network Opt-out

Downloadable Form

Offshore Subcontracting Disclosure

Downloadable Form

Request Provider Support

Online Fillable Form

Supporting Claim Documentation Upload

Online Fillable Form

Donate to DDAZ Foundation

Online Fillable Form

Smile Bag Request: Less Than 1,000

Downloadable Form

Smile Bag Request: Over 1,000

Downloadable Form