Delta Dental Claim Form For Research Foundation (RF)

RF employees submit this form to Delta Dental for services performed.

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Completing the PDF Form

  1. Read through all pages of the document to find specific instructions if any
  2. Enter requested information into the form
  3. Print the form
  4. Get required signatures
  5. Scan a copy of the signed form for your records
  6. Send the original, completed, signed form to:         

Delta Dental of New York
PO Box 2105
Mechanicsburg, PA 17055-2105

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Zachary Jenney

Zachary Jenney

RF Benefit Services

Phone: 716-645-4439


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Form Facts

Form Type: Downloadable, PDF document

Requirements: Adobe Reader

Updated: 10/12/2011

Owner: Delta Dental of New York