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Forms and Publications

Group and Member Forms
  • Membership Enrollment Form (excludes Dental Flex)
  • Membership Enrollment Form - Spanish
  • Dental Flex Enrollment Form
  • Membership Maintenance Form (includes Dental Flex)
  • Disabled Dependent/Michelle's Law Application
  • Group Administration Manual
  • Online Enrollment User Request Form
  • Online Enrollment Brochure
  • Group Master Application (Pooled)
  • Group Master Application (Individually Rated)
  • International Emergency and Expatriate Dental Program Claim Form With Instructions for Members
  • HIPAA Designated Contact Form
  • DDMN Capabilities Brochure
  • DDMN Web Site Brochure
To request a benefit summary for groups of 5-199 employees, please e-mail deltadentalconnect@deltadentalmn.org . Existing groups, please provide your group name or group number. New groups, please provide the product name, deductible, orthodontics type (traditional or orthodontic discount program, if applicable) and maximum.


Billing Forms & Calendars
  • Automated ASO ACH Authorization Form
  • Automated Risk ACH Authorization Form
  • Billing Reports Online User Request Form
  • Billing Reports Online Change Request Form
  • Billing Reports Online Brochure
  • 2013 Weekly Self Insured (ASO) Schedule
  • 2013 Monthly Fully Insured (Risk) Schedule
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