Veterans Affairs Dental Insurance Program (Vadip) Enrollment Authorization Form printable pdf download

Veterans Affairs Dental Insurance Program (Vadip) Enrollment Authorization Form

DELTA DENTAL USE ONLY

VETERANS AFFAIRS DENTAL INSURANCE PROGRAM (VADIP)

Enrollment Authorization

SECTION 1

Enrollment Type

 Veteran Enrollment (complete sections 2, 4 and 5; if adding a CHAMPVA beneficiary, complete section 3)

 CHAMPVA Beneficiary Enrollment (complete sections 2 - 5)

SECTION 2

Veteran Information (completion of this section is required)

Veteran

Last Name: ______________________________________ MI: _______ First Name: ___________________________________

Social Security Number: _______________________ Date of Birth (mm/dd/yy)____/____/____ Gender  M  F

Mailing Address: __________________________________________________________________________________________

City: ___________________________________ State: _______ ZIP Code: _____________ Country: _____________________

Home Phone: (

)________________________ Email: _______________________________________________________

 Yes, please email me instructions to access my Welcome Packet materials online.

SECTION 3

CHAMPVA Beneficiary Information

Primary CHAMPVA Beneficiary

Last Name: ______________________________________ MI: _______ First Name: ___________________________________

Social Security Number: __________________________ Date of Birth (mm/dd/yy)___/___/___ Gender  M  F

Mailing Address: __________________________________________________________________________________________

City: ___________________________________ State: _______ ZIP Code: _____________ Country: _____________________

Home Phone: (

)_________________________ Email: ______________________________________________________

 Yes, please email me instructions to access my Welcome Packet materials online.

List additional CHAMPVA beneficiaries:

Date of Birth

Social Security

Last Name

First Name

Gender

Address

Number

(mm/dd/yy)

 M  F

Page 1 of 2

Veterans Affairs Dental Insurance Program (Vadip) Enrollment Authorization Form