Community Care Network (CCN)
Online Dentist Inquiry Form

REQUESTOR INFORMATION

Fields marked with an asterisk (*) are required.

VA Authorization Referral Number*

Contact Person Name*

Dentist First Name*

Dentist Last Name*

Business Name

License State*

License Number*

Individual NPI (NPI 1)

Service Office Address*

City*

State*

Postal Code*

Office Phone*

Office Fax

Email Address*

NATURE OF INQUIRY

A Selection is required*.

A processed claim.

Please provide your Claim Number. Enter related comments in the Inquiry Details area below.

Claim Number*

The 13-digit Claim Number is located in the upper right portion of your Explanation of Benefits.

Response to Information Request (IR).

Please provide your Claim Number. Enter related comments in the Inquiry Details area below.

Claim Number*

The 13-digit Claim Number is located in the upper right portion of your Explanation of Benefits.

I am interested in participating in the Community Care Network (CCN).

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.

INQUIRY DETAILS

Inquiry Details*

ATTACHMENTS

Up to THREE files 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.