Get Enrollment/change Of Status/waiver Form - Delta Dental

Filling out the Enrollment/Change Of Status/Waiver Form for Delta Dental is crucial for managing your dental and vision benefits. This guide provides clear instructions on how to complete the form online, ensuring you can seamlessly submit your enrollment or changes.

Follow the steps to successfully complete your form.

1. Press the ‘Get Form’ button to access the Enrollment/Change Of Status/Waiver Form and open it in your preferred editor.
2. Complete the group information section, including the Delta Dental Group Number, Sublocation Number, and the designation of Salaried or Hourly. Update the effective date, date of hire or rehire, and the name of your employer.
3. Select the applicable options for employee, dependent, additions, terminations, or changes. Check ‘Yes’ if you wish to enroll in dental and/or vision plans, and choose your preferred network or plan options.
4. If you are adding or changing a dentist under DeltaCare DHMO, provide the dentist's name, address, and facility code. Make sure to include any changes for existing dependents.
5. Fill in your social security number, employee name, and alternate ID. Include your contact information, such as mailing address, email address, and phone number.
6. Indicate your marital status and date of birth. Ensure to select the appropriate option for gender.
7. Specify the reason you are submitting this form, whether for initial enrollment, COBRA, retiree status, or due to a qualifying event.
8. List all eligible dependents to be covered. Include the first and last name of each dependent, relation, birth date, and gender.
9. Select the desired dental and vision coverage options. Indicate if the spouse is covered under another dental plan and provide the name of the other carrier if applicable.
10. Review the final statement for accuracy, sign it, and date the form. Ensure it aligns with your selections and data entered.
11. Finally, save your changes, download a copy for your records, and proceed to print or share the form as needed.

Complete your Enrollment/Change Of Status/Waiver Form online today to ensure your dental and vision coverage is processed without delay.