Federal Employees Dental Program (FEDP) Online Dentist Inquiry Form

REQUESTOR INFORMATION

Required fields are denoted by a red asterisk (*).

*Country:

*Contact Person Name:
*Dentist First Name:
*Dentist Last Name:
Business Name:
*License State:
*License Number:
*Office Street Address:

*City:
*State:
*Postal Code:
*Office Phone:	USA: (xxx) xxx-xxxx
Office Fax:	USA: (xxx) xxx-xxxx
*E-mail Address:

NATURE OF INQUIRY

A selection is required.

	Enrollment and/or benefits. Please provide the following information on the subscriber. If the patient is not the subscriber, enter the patient name (First and Last) and patient’s date of birth in the Inquiry Details area below.
	*Subscriber First Name
	*Subscriber Last Name
	*Subscriber Date of Birth	/ / MM/DD/YYYY
	*Enter Subscriber ID:	(9-digit number without hyphens and spaces)

	A processed claim. Please provide your Claim Number. Enter related comments in the Inquiry Details area below.
	*Claim Number (13 digits) The 13-digit Claim Number is located upper right portion of your Explanation of Benefits.

	Response to Information Request letter. Please provide your Claim Number. Enter related comments in the Inquiry Details area below.
	*Claim Number (13 digits) The 13-digit Claim Number is located upper right portion of your Information Request letter.

	I am interested in participating in the Federal Employees Dental Program (FEDP) network. Enter related comments in the Inquiry Details area below.

	I am a Delta Dental network dentist and I have a question regarding participation. Enter related comments in the Inquiry Details area below.

	I am a Delta Dental network dentist and I have changed my office information. Enter related comments in the Inquiry Details area below.

INQUIRY DETAILS

* Inquiry details are required.

Attachments

Only one file may be attached per inquiry. Maximum file size is 15MB.
Accepted file types are doc, docx, xls, xlsx, xlsm, pdf, txt, jpg, jpeg, tif and tiff.

Security Question

Select one verification method Enter displayed characters Answer a simple question

*Response: