Dental Enrollment Request Form

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If you are pregnant or have diabetes
Form Title
Form Sub Title
your teeth and gums need special care.
Sign up for extra dental benefits* – at no extra cost – using the
form below.
Your Empire dental plan helps you take extra good care of your mouth.
Taking care of your teeth and gums is easy and can help keep your mouth free from infection. You should brush and
floss daily, and see your dentist regularly. While your dental plan most likely provides coverage for preventive care
services, by completing the form below you may be eligible* to get coverage for an extra dental cleaning (to help keep
your teeth healthy) or an extra periodontal maintenance procedure (to help keep your gums healthy) each benefit year.
For a healthy smile, sign up here.
Simply fill out the form below and mail, e-mail or fax it to us – whichever is easiest for you.
Mail to:
Clinical Integration Coordinator, PO Box 810, Minneapolis, MN 55440-0810
E-mail to:
Fax to:
1-800-821-5946
Dental Enrollment Request Form
Member name: _____________________________________________________________________________
Member address: ___________________________________________________________________________
Member phone number: (h) ______________________________ (w)__________________________________
I have diabetes
I am pregnant and my expected due date is: _________________________
Subscriber name: _______________________________________Subscriber ID number: _________________
For Group business only – Group name: ____________________________Group number: ________________
To the best of my knowledge and belief, I am being treated for diabetes or was pregnant as of the below signature date and will provide proof of such condition if
requested by Empire. Additionally, upon request, I will provide a written authorization to Empire to obtain medical records from my provider(s). If such condition
cannot be verified, I will not be eligible for coverage for the additional dental procedures available under this program.
Member signature:______________________________________________ Today’s date: ________________
Name of treating physician: ___________________________________________________________________
Phone number of physician: __________________________________________________________________
Questions? Just call the customer service number on the back of your Empire dental ID card.
* Coverage for additional cleaning is an optional benefit that may not be included in your plan. Check with your benefit administrator for details.
Services provided by Empire HealthChoice Assurance, Inc., a licensee of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans..
Dental Prime and Complete - 03555NYMENEBC 8/14
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