Get Ddpk0678 Enrollment Form. Ddpk0678 Enrollment Form - Upike

Completing the DDPK0678 Enrollment Form is an essential step in enrolling for dental coverage. This guide will streamline the process and ensure you fill out each section correctly, providing clarity and support throughout.

Follow the steps to complete your enrollment form smoothly.

1. Press the ‘Get Form’ button to obtain the DDPK0678 Enrollment Form and open it in your preferred editor.
2. Begin by providing your Personal Information in the designated fields. Enter your Social Security Number, followed by your name (Last, First, Middle Initial), and your birthdate.
3. Next, provide your contact details. Fill in your home phone number and complete your home address information, which includes the street number and name, city, state, and zip code.
4. Indicate your sex by circling 'M' for male or 'F' for female.
5. Choose the type of dental coverage you are applying for by checking the appropriate boxes: DeltaCare, Delta Dental PPO, or Delta Dental Premier.
6. If you are enrolling in DeltaCare, you must select a Primary Care Dentist (PCD) for yourself and any covered dependents. Use the PCD reference directory to find the appropriate name and number.
7. In the members’ section, list all covered individuals. Provide their names, birthdates, sex, and indicate if they are full-time students. If more space is required, attach a separate list.
8. For any status changes, complete the relevant sections to amend your contractual information, such as name changes or address changes, and explain your reason for the change.
9. In the 'Dependent Add or Delete' section, specify any dependents that need to be added or removed, including reasons such as marriage, divorce, or adoption.
10. Finally, review your enrollment form for any errors or omissions. You must sign and date the document to acknowledge your understanding of the provisions stated on the form.
11. Once completed, you can save changes, download, print, or share the form as required. Ensure you keep a copy for your records.

Start filling out your DDPK0678 Enrollment Form online today to secure your dental coverage.