Notice

On Monday, January 20th, our Provider Customer Service will be closed in observance of Martin Luther King Day. Member Customer Service hours will be from 8:00 AM to 5:00 PM. Due to the holiday, you may experience longer than normal wait times.

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 - Insured Clients (PDF, 3 pages, 52kb)

Authorization Form Granting Access to PHI - Self Funded Clients (PDF, 3 pages, 51kb)

Eligibility Enrollment Change Form (PDF, 2 pages, 22kb)
Use this form to submit new adds, changes, and terminations. 


COBRA Application 
(PDF, 1 page, 63kb)

Certification of Handicapped Child's Dependency Status
 
(PDF, 1 page, 13kb)
This form officially certifies the dependency status of a handicapped child. To be signed by the child's physician.