Opting out of the Delta Dental Medicare Advantage Network is a two-step process:
- Complete and submit the online form below for each practice TIN you wish to opt-out of the network.
- Digitally sign the confirmation document that will be emailed to you after you submit the electronic form below.
- To opt-out for more than one practice TIN, you must submit an opt-out form for each practice.
- If you are submitting the form for a group practice, your request to opt out of the Medicare Advantage network will be processed only when every participating dentist associated with the practice has submitted an opt-out form.
Enter the information requested in the form below and click the "Submit Form" button at the bottom of the form.
- The entire form is displayed below.
- All fields are required.
- The form must be completed in one sitting. If you exit the page before submitting the form, your information will not be saved.
- To opt-out for another practice TIN, return to this page to complete a second form.
Once the form is submitted, a document will be generated for you to sign digitally. The document will be emailed to the address submitted in this form.
To sign the document digitally, open the email and click the button labeled 'Review and Sign' and follow the instructions to sign and submit the document.
Contact Lori Langdeaux, Government Programs Policy Analyst, at firstname.lastname@example.org or 877-841-1478 if you have any questions about completing the form or the opt-out process.