Get Fafms0004

The Fafms0004 form is essential for enrolling or changing dental coverage through Hawaii Dental Service. This guide provides clear and concise steps to fill out the form accurately and effectively online.

Follow the steps to complete your enrollment or change request.

1. Click the ‘Get Form’ button to obtain the form and open it in the online editor.
2. Begin by completing the Group/Contact Information section. Enter the group name and group/division number, ensuring all information is printed legibly.
3. Input the contact person's name, email address, and phone number. This individual will be responsible for managing the enrollment process.
4. Next, select whether you are enrolling new employees, terminating coverage, or updating information. Clearly indicate the effective date of the change and provide the date of birth of the eligible employee.
5. Fill out the necessary details for the eligible employee, including their first name, middle initial, last name, address, and phone number. Mark if there is a new address.
6. For dependent information, list their names, relationships, and dates of birth. Indicate if you are enrolling or terminating coverage for each dependent.
7. Specify the reason for the change, such as open enrollment, loss of coverage, or marriage. Provide details as necessary.
8. Ensure you leave a blank box between each word when filling out the social security numbers. Verify that all information is accurate before proceeding.
9. Once you have completed the form, the group administrator must sign and date the authorization section to certify the information is correct.
10. After reviewing all entries, you can save changes, download a copy of the form, print it for your records, or share it securely as needed.

Complete your Fafms0004 form online today and ensure your dental coverage is up-to-date.