Forms and Documents

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Member Forms

• Claim Form - Use to file out-of-network claims
• Authorization Form - Authorization to release personal health information
• Personal Representative Form

Member Documents on Using Your Benefits

• PPO Plus Premier Network Information
• Enhanced Benefits Program - Additional dental benefits based on certain medical conditions
• To Go - Annual Maximum Carryover - Additional benefit that allows members to carryover unused annual maximums from one year to the next
• Check Up Plus - Optional benefit that waives preventive care from annual benefit maximum
• Member Connection - How to register and use the Delta Dental secure website to view benefits and claims
• How to Find a Network Dentist

Oral Health Documents

• Children's Oral Health - What do from baby teeth to 12-year molars
• Oral Health Factoids - Tips to maintain a healthy smile
• Monthly Mouthful and Social Media  - Website for timely oral health articles and how to connect to Delta Dental on social media

Enrollment Documents

• 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)
• DeltaVision Enrollment/Change Form (joint vision and dental employee application)

Employer Forms and Documents

• Application for Pooled Group (2-50 employees) and Voluntary PPO Coverage
• Application for Large Group Coverage (51+ employees)
• Quote Request Checklist (51+ employees)
• Notice of Financial Privacy Practices
• Guide for Administering Your Group Dental Benefit Plan
• ACH Form (fully-insured) - Form to have premium electronically withdrawn
• ACH Form (self-insured weekly) - Form to have weekly payment withdrawn