Provider Forms
Applications (for Massachusetts Dentists Only): Join the network, new location, recredentialing and non-participating provider
Join the Network
Review the Participating Dentist Rules and Regulations to learn more about contracting with Delta Dental of Massachusetts and submit the required documentation.
Join the NetworkRecredentialing application
Participating Massachusetts dentists are required to be recredentialed every 3 years. We’ll notify you when your recredentialing is due and confirm once approved.
Recredentialing applicationPractice Information Updates (for Massachusetts Practices Only)
Address change form
Use this form to change your payment and/or service office address(es). New enrollment contracting is required if the TIN or owner changes.
Address change formAdd a practice or location
Use this form if you are already a participating Dentist and want to contract at an additional location.
Add a practice or locationTax ID Number (TIN) change notification
Use this form to notify us of a TIN change. New enrollment contracting is required.
Tax ID Number (TIN) change notificationSpecialty change request form
Use this form if you are changing from one specialty to another.
Specialty change request formTermination request form
Use this form to cancel your enrollment in a service office and/or network.
Termination request formDirect deposit form
Use this form to sign up for direct deposit and Electronic Remittance Advice (ERA).
Note: All offices under the same TIN must use the same reimbursement method.
W-9 form
Use this form to report your TIN information or update the address used for annual 1099 statements.
W-9 form