Enrollment Form Ma
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1A DELTA DENTAL
Customer Sen/ice:
(617)886-1234
Toll Free
'
1. GROUP NAME:
Q
[ i f Delta Dental PPO Pius
^
15. FIRST NAME
A N D A FULL
DO Y O U
USE THIS DENTIST?
Individual+SP
Individual+CH
Individual+SP
Individual+CH
Individual+SP
Individual+CH
a n y o t h e r f a m i l y m e m b e r c o v e r e d by a n o t h e r dental p l a n ?
I certify that all information is true and correct to the best of my knowledge. Also, I understand that the effective date and termination date of my
E N R O L L M E N T FORM
Delta Dental of Massachusetts
PLEASE PRINT OR TYPE -
P.O. Box 9695
BE SURE FORM IS COMPLETED IN FULL TO ENSURE ENROLLMENT
Boston, Massachusetts, 02114-9695
(800) 872-0500
Corporate Office:
(617)886-1000
MA & NAT'L Toll Fre'i
(800)451-1249
Fax:
(617) 886-1293
w w w . d e l t a d e h t a l m a . c o m
2. EFFECTIVE DATE:
3. DATE OF HIRE:
4. GROUP NUMBER
5. SOCIAL SECURITY NO.
6. LAST NAME (Subscriber)
7. FIRST NAME:
8. DOB:
9. SEX:
10. HOME ADDRESS:
12. STATE:
11: CITY:
13. ZIP
PLAN SELECTION
14. PLAN: Select plan you are enrolling in:
High Plan
L o w Plan
Premier
I n d i v i d u a l
F a m i l y
I n d i v i d u a l
F a m i l y
|
|
$ 4 0 . 1 9
$ 9 4 . 3 5
$ 5 5 . 7 2
$ 1 3 0 . 8 0
P L E A S E LIST A L L ELIGIBLE DEPENDENT(S) COVERED UNDER YOUR POLICY
19. CHECK IF
DELTACARE OR VALUE PLAN ONLY
16. LAST NAME:
18.
17. DATE OF
DEPENDENT
(IF DIFFERENT
SEX
BIRTH
22.
IS OVER 19
20. CHOOSE A PCD FOR
M/F
CURRENTLY
FROM SUBSCRIBER)
21. PROVIDER #
EACH COVERED INDIVIDUAL
TIME STUDENT
SUBSCRIBER
CHILDREN
REASON FOR SUBMISSION (CHECK ONE)
23.
•
Transfer from sublocation.
_to_
•
New Addition
•
Individual
•
•
•
Family
•
Status change
•
Termination
•
Individual
•
•
•
Family
•
Add dependent to family
COBRA
•
Reinstatement
•
Reinstatement of Subscriber
•
Remove dependent
;
(name)
•
Individual
•
•
•
Family
•
Name change
•
Transfer to COBRA Sublocation
•
Address change
•
New addition of dependent formerly covered
•
Remove dep. from student status
(name)
under ID#
24. COORDINATION OF BENEFITS
A r e
•
y o u
O R
•
•
No
•
Y e s
If Y E S , p l e a s e indicate n a m e of Covered individual
.
OTHER DENTAL INSURANCE COMPANY:
EMPLOYER NAME:
POLICY HOLDER ID NO.:
EFFECTIVE DAY
25.
A r e
•
y o u
O R
•
any o t h e r family m e m b e r c o v e r e d by a n o t h e r m e d i c a l p l a n ?
•
Y e s
•
No
If Y E S , please indicate n a m e of c o v e r e d individual
.
EFFECTIVE DAY
OTHER MEDICAL INSURANCE COMPANY:
POLICY HOLDER ID NO.:
EMPLOYER NAME:
membership will be determined by my employer or plan sponsor in accordance with the underwriting guidelines of Delta Dental of Massachusetts. In
addition, if my employer requires employee contribution for this coverage, I authorize the deduction of this amount from my wages.
24.
S u b s c r i b e r
S i g n a t u r e
D a t e
B e n e f i t A d m i n i s t r a t o r A u t h o r i z a t i o n
D a t e
DDP-686 (08/10)
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