How Do I File a Self-Report Form for extra cleanings?
Once enrolled, you can file your confidential Self-Report Form after January 1, 2011. This will only take a few minutes to file online. You also have the option of downloading the form and mailing or faxing it to Delta Dental. Your dentist can also file a confidential Self-Report Form for you. When you file, you have five categories from which to select: • Pregnancy Please provide your estimated due date – ____/____/_____ • Diabetes • Diagnosed with periodontal disease • Experiencing kidney failure or undergoing dialysis • Suppressed immune system (Caused by radiation treatment; chemotherapy; HIV infection; or stem cell, bone marrow or organ transplant.) Note: If you have already received periodontal therapy and the claim(s) are on file with Delta Dental, you do not need to file a Self-Report Form. Your benefits have already been updated to provide coverage for the additional cleanings/periodontal maintenance visits.
