Delta Dental of Arizona

Member Forms & Documents

We make using your dental benefits easy. Browse our library of member forms and documents to find important resources you may need to manage your Delta Dental of Arizona plan. Additional forms may be available in the Member Connection. If you still can't find what you're looking for, please feel free to contact us.

Forms

Appeals & Grievances

Online Fillable Form

EFT Authorization: Individual/Direct Bill

Online Fillable Form

Electronic Check Payments

Online Fillable Form

Enrollment/Change of Status Form

Downloadable Form

Solicitud de Inscripción/Modificación

Downloadable Form

HIPAA Release (English/Spanish)

Downloadable Form

Legacy Individual Plan Cancellation

Downloadable Form

Legacy Individual Change of Status Form

Online Fillable Form

Additional Resources & Documents

Member Connection Registration Instructions

Informational Flyer

Out-of-Country Claims Submission (English/Spanish)

Informational Document

Printable Dentist Directory

Informational Document (updated monthly)

Our mission is to improve lives by promoting optimal oral health.

©Arizona Dental Insurance Service, Inc. dba Delta Dental of Arizona.

Delta Dental of Arizona 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.

Information provided on this site is for general education purposes only and is not intended as a diagnosis, treatment or a substitute for professional medical or dental advice, diagnosis or treatment. For even more oral health information, check out the Protect My Smile library on the Delta Dental Plans Association website.