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### Dental and Vision


Payment and Claims Information

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:
  • 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