Sign Up Request

August 13, 2025

Thank you for your interest! This feature is available only to Dentists who wish to accept payment from Delta Dental via direct deposit and who are registered Dentist Connection users. To find out more, please complete the form below and a Delta Dental representative will contact you.

*= Required Field

DENTIST OR CLINIC INFORMATION:		CONTACT PERSON INFORMATION:
*Dentist Name		*Contact Person Name
Address 1		Contact Person Email
Address 2		*Contact Person Phone
City		Contact Person Fax Number
State, Zip
*License Number
*Tax Identification Number
If Clinic, Name of Clinic
Preferred method of Direct Deposit Statement Delivery:	Web (Dentist Connection) Fax

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Delta Dental of Illinois is a part of Delta Dental Plans Association. Through our national network of Delta Dental
companies, we offer dental coverage in all 50 states, Puerto Rico and other U.S. territories.

Delta Dental of Illinois complies with all applicable Federal and State civil rights laws. Delta Dental of Illinois does not discriminate, exclude people, or treat them differently on the basis of gender, sex (which includes discrimination on the basis of sex characteristics, including intersex traits; pregnancy or related conditions; sexual orientation; gender identity or expression; and sex stereotypes), race, color, religious creed, national origin, citizenship, age, physical or intellectual disability, protected veteran status, marital status, genetic information, or any other characteristic protected by law.

Direct Deposit - Sign Up Request