Delta Dental Claim Form

Claim Form Instructions

Direct Deposit Enrollment Form (For South Dakota participating providers only.)

IRS W-9 Form

Understanding the National Provider Identifier

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Provider Dispute Form

Dental offices must notify Delta Dental's Department in writing when the dentist:

Opens or closes an office location

Changes his or her name

Changes address

Buys or sells a practice

A TIN Enrollment form is required when the dentist:

Adds a new practice location

Makes any changes to the tax identification number of changes to the type of business entity, e.g.,
     partnership or corporation.

Download forms here (requires Adobe Acrobat Reader):

Dental Office Notice of Address Change (PDF)
Taxpayer ID Number Enrollment Form (PDF)
Notification of Sale of Practice (PDF)

Forms should be mailed or faxed to:

Delta Dental of South Dakota
PO Box 1157
Pierre, SD 57501
Fax: 605-224-0909