Member Change Form - Delta Dental
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1MEMBER CHANGE FORM
HDS Use Only
Date Processed
Processed By
OAHU:
TOLL FREE:
PHONE: 529-9230
1-800-232-2533, EXT 230
FAX:
529-9207
1-866-590-7989
.
A
Group Information
/
Group / Division #
Group Name
-
-
Contact Name
Contact Phone #
ext
B.
Update Type
Indicate the transaction type requesting.
Add Family Members
Termination Terminate Family Members
Reinstatement
Change / Correction to Information
Address / Email Change
Transfer from _____________ to _____________
C.
Reason for Change
Indicate the reason / qualifying event of the change.
Open Enrollment
Loss of Coverage
Probation
Marriage (Date) _________ / ________ / _________
Newborn
Adoption (Date) _________ / ________ / _________
Legal Guardianship (Date) _________ / ________ / ________
D.
Subscriber
Complete the subscriber information.
Effective Date of Change / Update
Social Security Number
Birth Date
Sex
/
/
2
0
-
-
/
/
M
F
Last Name
First Name / Middle Initial
Address
City
State
Zip Code
Phone Number
Email Address
(
)
-
Family Members
Complete this section to add or terminate family member(s). Please attach a separate sheet for additional
E.
dependent(s). Be sure to include the Eligible Employee’s Social Security Number and Name when attaching additional sheets.
Social Security Number
Birth Date
Relation
Sex
Spouse
Child
M
Full-time student
-
-
/
/
Domestic Partner
F
Disabled Child
Last Name
First Name / Middle Initial
Social Security Number
Birth Date
Relation
Sex
Spouse
Child
M
Full-time student
-
-
/
/
Domestic Partner
F
Disabled Child
Last Name
First Name / Middle Initial
Social Security Number
Birth Date
Relation
Sex
Spouse
Child
M
Full-time student
-
-
/
/
Domestic Partner
F
Disabled Child
Last Name
First Name / Middle Initial
F.
Authorization
I certify that the information provided is true, correct and meets the terms and conditions of the HDS Agreement.
Authorized Group Administrator Signature
Date
FORM NO. FAFMS0005 (05/10)
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