Delta Dental Enrollment Change Form - Arlingtonva printable pdf download

Group Enrollment Application

Delta Dental of Virginia

(New Enrollment/Changes to Enrollment)

4818 Starkey Road, Roanoke, VA 24018

(540) 989-8000 · (800) 237-6060

Fax: (540) 776-8109

IMPORTANT: Incomplete information will delay enrollment. Please print using a ball point pen, press firmly and print clearly.

Group Name: Arlington County Government

Effective Date:

Group No: 6289

Sublocation/Division No:

Section A: ENROLLMENT/CHANGE (For qualifying event provide date and reason in section D)

New Hire

ADD dependent/spouse

Coverage Change

Reinstatement

Open Enrollment

DROP dependent/spouse

COBRA (Effective Date ___/___/___)

Cancel Coverage

Change/Update Information

Name - Previous Name _______________________

Address

Telephone

Other_________________________

Decline Coverage - I understand that I have been offered and have elected to decline coverage under my employer sponsored dental plan with Delta

Dental at this time. I will not be eligible to enroll until the next open enrollment period or in the event of a qualifying event during the coverage period.

(Sign, date and complete first line of Section B.) Signature ______________________________________________

Date _______________________

Section B: EMPLOYEE INFORMATION

Last Name

First Name

Social Security Number

Group Assigned ID (if applicable)

Mailing Address (#, Street, Apt)

City

State

ZIP

Home Telephone

Date of Birth

Gender

Marital Status

If married, will your spouse or dependents

have coverage under another group dental

Male

Single

Yes

plan on the date this plan becomes effective?

(

)

Female

Married

I agree to receive communications regarding my group plan via the email address that I have

Email Address

supplied on this application. If you do not want to receive communications about your policy via

email, please check this box

Date of Hire

Number of Hours Worked Per Week

Payroll Status

Section C: COVERAGE

Coverage Type (check one)

Product (check one)

Individual

Individual Plus One

Delta Dental PPO

plus Premier

Individual/Children

Individual/Family

Section D: LIST ALL MEMBERS TO BE ENROLLED (Check Reason for Change Below)

DELTACARE ONLY

Sex

Date of Birth

Last Name (if different)

First Name, MI

Relationship

(M/F)

(MM/DD/YYYY)

Dentist (First/Last Name)

Provider#

Add

Drop

Add

Drop

Add

Drop

Add

Drop

Date of Qualifying

Reason(s) for Qualifying Event

Marriage

Loss of other group coverage

Divorce

No longer dependent

Event

Birth or adoption

Death of spouse/dependent

Other ___________________________________________

Section E: AUTHORIZATION AND CERTIFICATION

I authorize dentists, dental office personnel, and other health care professionals and entities to disclose to Delta Dental of Virginia, its agents and employees

(including, without limitation, its claims and customer service personnel) all information necessary to determine (1) eligibility for coverage and (2) covered

benefits. This authorization is made for each individual to be enrolled or affected by this change. The authorization is valid for 30 months from the date this

form is signed for underwriting purposes. The authorization is valid for the term of coverage for the purpose of collecting information in connection with claims

for benefits. The applicant or the applicant’s authorized representative is entitled to receive a copy of the authorization form.

I understand that my selection of coverage may be changed only during the open enrollment period of each year unless I experience a qualifying event listed

under “Reasons for Change” in Section D. Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an

application or files a claim containing false or deceptive statement may have violated state law. I certify that the information supplied by me on this form is

accurate to the best of my knowledge. Under DeltaCare, in the event you fail to select a dentist in the DeltaCare network, you hereby authorize Delta Dental

to select a dentist on your behalf so that your enrollment may be complete. You also authorize Delta Dental to change your selection, if you select a dentist

not in Delta Dental of Virginia DeltaCare network or your dentist no longer participates with the Delta Dental of Virginia DeltaCare network.

Signature: ____________________________________________________________________________

Date:_________________________________

EC#01.2012