Training Acknowledgement Form

Thank you for taking Delta Dental’s Medicare training. Please submit the following information in order to complete your training.

PLEASE NOTE: Do not enter an NPI or Social Security number in place of the business tax ID number (TIN). We require the business TIN to be able to appropriately document your training acknowledgement submission.

Business Tax Identification Number (TIN). Do not include hyphens.*
Confirm TIN*
* *
Indicate Training Course(s) Taken*

By submitting this form, I hereby certify that all persons associated with the TIN entered above have completed the Delta Dental’s Medicare training indicated above for this calendar year.