Forms and documents Oregon

Handbooks

• Delta Dental of Oregon Provider Handbook - guide for dental office staff in working with us
• Delta Dental of Oregon Medicare Advantage Providers Handbook – guide for dental providers and office staff in the Medicare Advantage network

Claims and payments

Find out how to file fees and submit claims electronically

• Claims form - Advise your patients to log in to their Member Dashboard to access the ADA claim form
• Delta Dental of Oregon Clinical Guidelines
• ERA form - Enroll to receive Electronic Remittance Advice (ERA)
• Refund submission form - Request refunds for overpayment
• Electronic Remittance Explanation Codes - details about Claims Adjustment reason codes, also called HIPAA Claims Adjustment Reason Codes - Facets
• Sample EOPs - See what an explanation of payment (EOP) looks like
• Sample EOBs - See what an explanation of benefits (EOB) looks like

Authorizations

• Member Disclosure Authorization form - Authorizes the release of health information
• Request for confidential communications - Request to receive protected health information
• Medicare Member Disclosure Authorization form - Authorizes the release of health information for Medicare Advantage Members.

Oregon credentialing

• Oregon Dental Credentialing Application - Join the Delta Dental network
• Oregon Dental Recredentialing Application - Continue being a part of the Delta Dental network

Miscellaneous

• Health through Oral Wellness® - Enroll yourself or a patient in this program
• Health through Oral Wellness Benefit Grid
• Notice of Address Change and Additional Location - Let us know if you have changed addresses or added a location
• Notice of Sale of Practice Form - Let us know if you have sold your practice
• OEBB HIP Member Form
• Non-Covered Services Waiver – signed consent for non-covered services; for patient files only
• Understanding NPIs - Understanding how we use your National Provider Identifier
• Provider diversity data - submit diversity, equity, and inclusion focused information for yourself (contracted practitioners)
• Clinic diversity data - submit diversity, equity, and inclusion focused information for contracted clinics/facilities