Complaint Form

If you have concerns regarding misleading or incorrect information on your Explanation of Benefits, dental treatment received or the billing practices of a dentist you have received treatment from while covered by Delta Dental, please use this form to file your complaint. You may also report your concerns by calling us at 1-888-227-6004. *Required

Your Information

Your name*

Your name* is mandatory

Patient name*

Patient name* is mandatory

Email*

Email* is mandatory

Phone*

Phone* is mandatory

Phone number should be numbers only, without dashes. For example: 5405555555.

Dental Provider Information

Dentist's name*

Dentist's name* is mandatory

City*

City* is mandatory

State*

Please select at least one of the items

Zip code*

Zip code* is mandatory

Complaint(s)

What is your complaint?*

This field is mandatory