Vital Information - Survivor'S Benefit Checklist Page 4

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INDEMNITY OPTION Delta Dental PPO plus Premier - Group #9949
•
An indemnity plan allows enrollees to select a dentist of their choice throughout the United States and
worldwide without using a provider network.
•
The plan limits the amount of paid coverage for each specific type of dental treatment – Members pay
any remaining balance due based on the type of dental treatment they receive.
•
The amount of your monthly premium copayment is deducted from your monthly pay warrant according
to the number of enrolled dependents.
For more information, contact:
Delta Dental
1-800-225-3368
:
INDEMNITY OPTION
For more information or a list of member dentists, contact the plans at:
DeltaCare USA
1-800-422-4234
Premier Access
1-888.534-DHMO (1-888-534-3466)
SafeGuard 1-800-880-1800
safeguard.net
Western Dental 1-866-859-7525
II.
Dental FORMS
•
Dental Plan Enrollment Authorization - STD 692
•
Dental Plan Direct Payment Authorization - STD 696
•
Affidavit for Economic Dependent Children - CalHR 025
•
Affidavit for Domestic Partners Being Claimed as Economic Dependents - CalHR 680
III.
Dental COBRA Forms
•
COBRA Election Form - CalHR 767
•
COBRA Calendar
IV.
Savings Plus Program
Savings Plus
Website:
Saveplus@dpa.gov
EMAIL
Contact the Savings Plus Service Center at:
1-(855) 616-4SPN (4776
FAX (847) 554-1804
Vision Service Plan
Vision Service Plan (VSP)
3333 Quality Drive
Rancho Cordova, CA 95670
1-800-877-7195
•
Vision Plan Enrollment Authorization - STD 700
•
Premier Vision Plan Enrollment Authorization - CalHR 774
•
Vision Plan Direct Payment Authorization - STD 703
•
Retiree Vision Plan Deduction and Enrollment Authorization - CalHR 695
•
Vision Services Plan Brochure/Enrollment Form
4

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