Enhanced Dental Benefits Enrollment Form printable pdf download

Enhanced Dental Benefits Enrollment Form

Dear HMSA Dental Member:

This is an application for Enhanced Dental Benefits from the HMSA dental plan. This program

will provide additional preventive and/or diagnostic services if you have been diagnosed with

conditions identified in the Oral Health for Total Health program.

Please fill out the below and also have your physician fill out the remaining information. All

information requested must be provided to qualify for participation in the Enhanced Dental

Benefits.

The completed application can be mailed to the address listed at the end of this form. Please

allow 10 to 12 business days for your form to be evaluated and approved for enrollment. Once

we have completed evaluation of your form, we will mail a Welcome Letter to you as

confirmation you have qualified for participation and enrollment into the program.

Member Information

Subscriber Name_____________________________________________________________

Member Name_________________________________________Date of Birth____________

Member Address_____________________________________________________________

City___________________________ State__________________ ZIP Code______________

Member Telephone Number # (home)______________________(cell)___________________

Member Email Address________________________________________________________

Member agrees to receiving electronic communication about the Oral Health for Total

Health program.

HMSA Subscriber ID__________________________________________________________

I hereby affirm that I have been diagnosed with the condition(s) checked on the back:

Member Signature_______________________________Date_________________________

Enhanced Dental Benefits Enrollment Form