Notice

Saturday, 10/17 through Sunday, 10/18, due to system maintenance, the following services Claims Submissions, Eligibility Updates, and Procedure Code Lookup will be current as of Friday 10/16 and updated once maintenance is complete. 

 

To view benefit information and claim status at any time, you can sign into your account or use our Interactive Voice Response System 24/7 at (800-452-9310).

Dental Forms Library for Employers

Find the application or form that relates to your needs and easily download and print, or submit online.

Authorization Form Granting Access to PHI (PDF, 1 page, 52kb)

Enrollment/Change Form (Dental) (PDF, 2 pages, 627kb)
Use this form to submit new adds, changes, and terminations.
Enrollment/Change Form (Vision) (PDF, 1 pages, 378kb)
Use this form to submit new adds, changes, and terminations. 
Disabled Dependent Verification Certification (PDF, 1 page, 13kb)
This form officially certifies the dependency status of a disabled dependent. To be signed by the child's physician.