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Form for reporting potential fraudulent activity

Please complete and submit the following form to report possible fraudulent activity to Delta Dental.

Fields marked with an asterisk (*) are required.

Describe the fraudulent activity you would like to report

Description (2000 character limit)

0 / 2000

Claim number associated to this activity

Patient name associated to this activity

Member ID associated to this activity

Submitter has documentation they are willing to provide if requested

Name of the individual or facility performing the potential fraudulent activity

Name of individual

Facility or provider office name

Address

City

State

ZIP code

Phone number

Email

Additional names involved

Address

City

State

ZIP code

Phone number

Submitter's name

Name

Address

City

State

ZIP code

Phone number

Email