If you visit an out-of-network dentist, you may be responsible for paying for your treatment at the time of service.  To request reimbursement:

1) Obtain a detailed receipt, including:

• Dentist's name and address (including city/country)
• Services performed
• List of teeth treated
• Currency of payment (such as U.S. dollars)

2)  Submit a claim to Delta Dental to request reimbursement of covered treatments:

• Download and print a claim form at: deltadentalins.com/enrollees
• Submit your form and detailed receipt (see above)
• If records or receipts are not in English, translate as much as possible into English, or provide an English patient statement
• Include your current address and phone number so Delta Dental can reach you with any questions

NOTE: As with any dental plan, the plan reimbursement may not cover the entire treatment cost.

To visit the Delta Dental website, go to www.deltadentalins.com.