Membership Maintenance Form - Delta Dental Of Minnesota printable pdf download

Delta Dental of Minnesota

Membership Maintenance Form

PART A - EMPLOYEE INFORMATION

Last

First

Middle Initial

Social Security Number

Employee’s

Name:

Male

Female

Single

Married

Widowed

Divorced

Legally Separated

Date of Birth (Month-Day-Year)

Gender:

Marital

Status:

Address

Day Phone Number

Evening Phone Number

Employee’s

Address:

Check If

City

State

Zip Code

New Address

PART B – CHANGE REQUEST - Check all categories that apply and provide information requested by category.

Name Change

Terminate Employee and All Dependent Coverage

Former Name:___________________________________

Date of Termination: __________/__________/__________

New Name:

___________________________________

Date Coverage Ends: __________/__________/__________

Change Employee Group/Subgroup (Move individual

Millennium Choice Groups Change Plan Option at Open Enrollment

to different subgroup, including to COBRA subgroup)

Plan Option I - Delta Dental PPO

Plan Option II - Delta Dental Premier

From:________________ To:______________________

For DeltaCare Groups Change Clinic Code to: ______________

Obtain Clinic Code from DeltaCare Provider Directory

Effective Date of Change

: _________/__________/__________

Enroll in Voluntary Discount Orthodontic Program

Change Coverage Type, Add or Drop Dependent Due to Qualifying Event – List Qualifying Event Code next to correct Coverage

Type/Change Request Category. Complete Part C if Adding or Dropping Dependent(s). Qualifying Event Code: A – Adoption B – Birth D

– Divorce/Legal Separation E – Death L – Loss of Coverage M – Marriage O – Open Enrollment S – Dependent No Longer Eligible

Qualifying Event Code

Coverage Type / Change Request Category

Date of Qualifying Event

Effective Date of Change

Employee Only

Employee & Spouse

Employee & Dependent Child(ren)

Family

Add or Drop Dependent - No Coverage Type Change

PART C – DEPENDENT INFORMATION – Adding or dropping dependents may require a Coverage Type change in Part B.

Relationship

First Name, Middle Initial, Last Name

Date of Birth

Full Time

(Include Last Name Only if Different From Employee’s)

Gender

Add Drop

To Employee

Month/Day/Year

Student?

Unmarried?

Spouse

Dependent Child

PART D – EMPLOYEE SIGNATURE – Sign and date form as verification of your enrollment change.

I choose to make changes as indicated on this form and authorize payroll deduction, if applicable. If Part E is completed, I have elected to continue

coverage under this plan due to the qualifying event indicated below and I understand that in order to retain my coverage continuation, I must meet the

required payment obligations and/or other conditions as may be required.

Employee Signature:

Date:

PART E – COBRA – Employee Note: Complete Only if enrolling for COBRA benefits Employer Note: May require subgroup change.

Qualifying Event Number:

1 Employee Termination or Reduction of Work Hours

3 Employee Total Disability

5 Employee Eligible For Medicare

4 Divorce or Legal

6 Dependent No Longer Eligible

2 Employee Death

Separation

Event Number

Coverage Continuation Applies To:

Date of Qualifying Event

Social Security Number

Employee & All Dependents Currently Enrolled

Employee Only

Spouse Only

Dependent(s) Only – List Names in Part C

Employee & Spouse

Employee & Dependent Child(ren)

–List Names in Part C

PART F – GROUP INFORMATION - THIS PART TO BE COMPLETED BY EMPLOYER

Group Name:

Group & Subgroup Numbers:

Group Representative’s Signature:

Date:

Phone Number:

Send Original Copy to Delta Dental

Retain Copy For Your Records

E02 01/27/09

Membership Maintenance Form - Delta Dental Of Minnesota

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