Member Forms - Delta Dental of Illinois 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by selecting the type of transaction at the top of the form. Check all applicable boxes for 'Statement of Actual Services' or 'Request for Predetermination/Preauthorization'.
3. Fill in the Primary Payer Information section. Enter your name, address, and subscriber identifier (SSN or ID#). Don’t forget to indicate your gender and relationship to the primary subscriber.
4. Complete the Patient Information section by providing details such as date of birth and employer name. Ensure accuracy as this information is crucial for processing.
5. In the Record of Services Provided section, list each service rendered along with corresponding dates and procedure codes. Use the provided tooth number system for clarity.
6. Review all entered information carefully before submitting. Make sure all required fields are filled out correctly to avoid delays.

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