Delta dental Oregon

Dental Provider Correspondence Request

This form is used to submit your narrative and supporting documentation such as explanation of payment (EOP), clinical records, chart notes, and x-rays. Submission of this request without documentation will result in processing delays. Attach all files using the ATTACH FILES feature at bottom of form. All services are subject to eligibility and plan provisions in effect at the time services are rendered.

All fields are required.

Section 1 - Provider Information

Provider Name

Phone Number

Provider Email

Provider Tax ID

Address

City

State

Zip

All fields are required.

Section 2 - Member Information

Member Name

Date of Service

Member ID #

Claim Number (If Available)

All fields are required.

Section 3 - Please enter your request in the space below.

Attaching documents: Please attach your documents to the specified attachment categories. Multiple documents and/or images can be attached for each category. Multiple attachments for one category cannot be uploaded individually. You must “select all” from your local device and upload all documents at one time. Once you have uploaded your documents you will receive a confirmation message stating the number of files selected. If you uploaded a single document, the document name will display.

Chart notes:

X-rays:

Narrative and Other Supporting Documentation:

Name of Requestor

Date

Questions?

Please call Customer Service at 888-217-2365.
Monday through Friday from 7:30 a.m. to 5:30 p.m. Pacific Time.

You may also find answers by logging in to your Member Dashboard

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