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TRICARE Retiree Dental Program Forms

Authorization for Electronic Funds Transfer (EFT)

To get started with an electronic funds transfer (EFT) for your TRICARE Retiree Dental Program monthly premiums, complete this form and return it to:

Federal Government Programs
Delta Dental of California
PO Box 537008
Sacramento, CA 95853-7008

Fax: 1-916-851-1559

Claim Form (United States)

Participating dentists will normally file claims on your behalf. If you must submit a dental claim form, send the completed the claim form and supporting documents to:

Deltal Dental of California
P.O. Box 537007
Sacramento, CA 95853-7007

Claim Form (Overseas)

Participating dentists will normally file claims on your behalf. If you must submit a dental claim form, send the completed the claim form and supporting documents to:

Delta Dental of California,
P.O. Box 537006
Sacramento, CA 95853-7006
United States of America

Enrollment Application

This form is used to enroll in the TRICARE Retiree Dental Program. Submit this completed form along with your initial premium payment to:

Delta Dental Plan of California, Federal Services
P.O. Box 537008
Sacramento, CA 95853-7008

Patient Grievance Form

Enrollee requests for Delta Dental to investigate grievances must be submitted in writing to the address below. The grievances must be documented on the reverse side of this form and must specify the grievance with requested outcome and any additional records, documents or billing information to support the grievance.

Delta Dental of California
Federal Services Division
P.O. Box 537015
Sacramento, CA 95853-7015

Last Updated 12/6/2013