Form Ddp-605 - Enrollment Form printable pdf download

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ENROLLMENT FORM

PLEASE PRINT OR TYPE -

BE SURE FORM IS COMPLETED IN FULL TO ENSURE ENROLLMENT

Delta Dental of Massachusetts

PO Box 9695

Boston, Massachusetts 02114

Customer Service (617) 886-1234

Toll Free

(800) 872-0500

Corporate Office: (617) 886-1000

MA & Nat's Toll Free (800) 451-1249

Fax:

(617) 886-1293

1. GROUP NAME:

2. EFFECTIVE DATE:

3. DATE OF HIRE:

4. GROUP NUMBER:

013190

January 1, 2014

5. SOCIAL SECURITY NO:

6. LAST NAME (Subscriber):

7. FIRST NAME:

8. DOB:

9.SEX:

10. HOME ADDRESS:

11. CITY:

12. STATE:

13. ZIP:

PLAN SELECTION

14. PLAN: Select plan you are enrolling in:

… Delta Dental Premier … Delta Dental PPO … Delta Dental PPO Plus Premier … DeltaCare

… The Value Plan

If DeltaCare or the Value Plan is selected, each subscriber &

dependent must choose a DeltaCare Primary Care Dentist (PCD).

PLEASE LIST ALL ELIGIBLE DEPENDENT(S) COVERED UNDER YOUR POLICY

19. CHECK IF

DELTACARE OR VALUE PLAN ONLY

16. LAST NAME

17. DATE OF 18.

DEPENDENT

IS OVER 19

22. DO YOU

15. FIRST NAME

BIRTH

SEX

(IF DIFFERENT

20. CHOOSE A PCD FOR EACH

CURRENTLY

AND A FULL

21. PROVIDER #

USE THIS

M/F

FROM SUBSCRIBER)

COVERED INDIVIDUAL

TIME STUDENT

DENTIST?

SUBSCRIBER

SPOUSE

CHILDREN

REASON FOR SUBMISSION (CHECK ONE)

23.

… New Addition

… Transfer from sublocation _________ to _________

… Individual

… Individual + 1

… Family

… Status change

… Termination

… Individual to Family

… Individual + 1 … Family to Individual

… Add dependent to family

COBRA

… Reinstatement

… Reinstatement of Subscriber

… Remove dependent _________________ name

… Individual

… Individual + 1

… Family

… Name change

… Transfer to COBRA Sublocation ____________

… Address change

… New addition of dependent formerly covered

… Remove dep. from student status _______________ name

under ID # _______________________________

COORDINATION OF BENEFITS

24.

… you

… any other family member covered by another dental plan?

… No

… Yes

Are

If YES, please indicate name of covered individual _________________________ .

OTHER DENTAL INSURANCE COMPANY:

EMPLOYER NAME:

POLICY HOLDER ID NO.:

EFFECTIVE DATE:

… you

… any other family member covered by another medical plan?

… No

… Yes

Are

25.

If YES, please indicate name of covered individual _________________________ .

OTHER MEDICAL INSURANCE COMPANY:

EMPLOYER NAME:

POLICY HOLDER ID NO.:

EFFECTIVE DATE:

I certify that all information is true and correct to the best of my knowledge. Also, I understand that the effective date and termination date of my

membership will be determined by my employer or plan sponsor in accordance with the underwriting guidelines of Delta Dental of Massachusetts. In

addition, if my employer requires employee contributions for this coverage, I authorize the deduction of this amount from my wages.

Subscriber Signature

Date

Benefit Administrator Authorization

Date

26.

DDP-605 (6/08)

Form Ddp-605 - Enrollment Form

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