Benefit Survey - Dental Provider

This survey pertains to your CURRENT dental provider.

If you are in the DeltaCare USA HMO plan and are uncertain of your provider/office, you may contact Customer Service at (800)422-4234.

Please complete and submit your survey by 12:00 PM Friday, August 3, 2012 to be entered into a survey drawing.

Again, thank you for your participation!!!
Name: 


  1. What is the name of your provider or dental office?


  1. In what city is your provider or dental office located?


  1. Are you or any covered dependent currently receiving or are scheduled to receive ORTHODONTIA treatments/care?
    Yes
    No


  1. What dental plan are you in?
    DeltaCare USA HMO
    Delta Dental PPO
    I waive my dental coverage through L.A. Care