Veterans Affairs Dental Insurance Program (VADIP) Online Dentist Inquiry Form

REQUESTOR INFORMATION

Required fields are denoted by a red asterisk (*).

*Contact Person Name:
*Dentist First Name:
*Dentist Last Name:
Business Name:
*License State/Territory:
*License Number:
*Office Street Address:

*City:
*State/Territory:
*Postal Code:
*Office Phone:	USA: (xxx) xxx-xxxx
Office Fax:	USA: (xxx) xxx-xxxx
*E-mail Address:

NATURE OF INQUIRY

A selection is required.

	Enrollment and/or benefits. Please provide the following information on the subscriber. If the patient is not the subscriber, enter the patient name (First and Last) and patient’s date of birth in the Inquiry Details area below.
	*Subscriber First Name
	*Subscriber Last Name
	*Subscriber Date of Birth	/ / MM/DD/YYYY
	*Enter Subscriber ID:	(9-digit number without hyphens and spaces)

	A processed claim. Please provide your Claim Number. Enter related comments in the Inquiry Details area below.
	*Claim Number (13 digits) The 13-digit Claim Number is located upper right portion of your Explanation of Benefits.

	Response to Information Request letter. Please provide your Claim Number. Enter related comments in the Inquiry Details area below.
	*Claim Number (13 digits) The 13-digit Claim Number is located upper right portion of your Information Request letter.

	I am interested in participating in the Veterans Affairs Dental Insurance Program (VADIP) network. Enter related comments in the Inquiry Details area below.

	I am a Delta Dental network dentist and I have a question regarding participation. Enter related comments in the Inquiry Details area below.

	I am a Delta Dental network dentist and I have changed my office information. Enter related comments in the Inquiry Details area below.

INQUIRY DETAILS

* Inquiry details are required.

Attachments

We are experiencing a temporary issue with attachments. If you are NOT planning to submit an attachment with your inquiry, please proceed. If you are needing to submit attachments to support your inquiry or question, please submit a written inquiry (along with all supporting documentation) to Delta Dental at the following address:

Delta Dental of California – Federal Government Programs P.O. Box 537007 Sacramento, CA 95853

Our team is working to resolve this issue as quickly as possible. Thank you for your patience and we apologize for any inconvenience this may cause

Security Question

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