Delta Dental Ppo - Plus Premier Federally Compliant Plans Enrollment Form printable pdf download

Delta Dental PPO Plus Premier Federally Compliant Plans

Enrollment Form

Employee Name: ________________________

____________________________________ Date of Birth: ________________ Sex:

Street Address: ___________________________________________ City: __________________

_________________ State: ______ Zip: _________

Social Security #: ________________________ E-mail: ______________________________________________________________

Group/Subgroup

Location Code

SEE REVERSE SIDE OF THIS FORM FOR PRIVACY POLICY STATEMENT

Employer :

_______________________________________________________

Please list all Covered Persons under the age of 19 to be enrolled. Each Covered Person's SSN MUST be provided

Covered Person: _______________________________________ Sex: _ _____ SSN: ___________________ Date of Birth: ___________

Covered Person: _______________________________________

Sex: _ _____ SSN: ___________________ Date of Birth: ___________

Covered Person: _______________________________________

e S

: x

_ _

S S

: N

_ _

___________ Date of Birth: ___________

Covered Person: _______________________________________

Sex: ______ SSN: ___________________ Date of Birth: ___________

Covered Person: _______________________________________

Sex: ______ SSN: ___________________ Date of Birth: ___________

Covered Person: _______________________________________

Sex: ______ SSN: ___________________ Date of Birth: ___________

Program Selec on (Choose One)

Enrollment/Eligibility Update Informa on:

Eligibility Date

ctive Date of Update/Change/Termination

Pediatric Only Low Plan

Pediatric Only High Plan

Mail to:

Program Type

Your Cost

Program Type

Your Cost

Delta Dental of Oklahoma

(Choose One)

A n: Health Care ReformTeam

One Covered Person $ 30.51 per month

One Covered Person $ 18.80 per month

Change in Status for:

PO Box 54709

Subscriber

Dependent(s)

Oklahoma City, OK 73154

Two Covered Persons $ 61.02 per month

Two Covered Persons $ 37.60 per month

Reason for Change:

Fax to:

Name Change

Marriage

Three or more

1-405-607-2199

$ 91.53 per month

$ 56.40 per month

New Address

Divorce

Covered Persons

Other

Email to:

Adop on/Guardianship*

HCR

Termin on of Coverage

Group/Subgroup Transfer

*Legal Documents Must Be Submitted for Update/Change

To Group/Subgroup

From Group/Subgroup

Warning:

Any person who knowingly and with intent to injure, defraud, or deceive any insurer, provides false inform on herein and makes any claim for the proceeds of an insurance policy containing any

false, incomplete, or misleading inform on is guilty of a felony.

By signing this form, I agree to con nue enrollment as provided by the contract between my Employer and Delta Dental of Oklahoma and acknowledge I have read the privacy policy on the back of this form

Applicant Signature:

Date:

TURN OVER/NEXT PAGE >>

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PedEnroll (10/15)