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Employee Forms

• Enrollment/Change Application - English version of employee enrollment form
  
• Enrollment/Change Application - Spanish version of employee enrollment form
  
• Voluntary PPO Application/Change Form (Employee English version)
  
• Voluntary PPO Application/Change Form (Employee Spanish version)
  
• Personal Representative Appointment Form
  
• Individual Authorization Form
  

Employee Dental Benefits Information

• How to Use To Go^SM Benefits - this document explains how To Go works and how employees can increase their annual benefit maximums. 
• How to Use the Enhanced Benefits Program - employees can access additional dental benefits based on certain medical conditions. New medical conditions have been added in 2010 to include high-risk cardiac conditions, suppressed immune systems, kidney failure or dialysis, and cancer treatments. This document outlines how employees can sign up for additional benefits. 
• Subscriber Connection - this document describes how employees can access the Subscriber Connection to view dental benefits online and find a dentist on the Delta Dental website. 

Employer Forms

• Application for Pooled Group and Voluntary PPO Coverage - effective 1/2010 Small Group Enrollment Form for New Groups
• Delta Dental on the Internet - Web Site Information
• Notice of Financial Privacy Practices
• Guide for Administering Your Group Benefit Plan
• ACH Form (fully-insured) - Form to have premium electronically withdrawn 
• ACH Form (self-insured weekly) - Form to have weekly payment withdrawn