Get Employee Change Form - Dental Select

Filling out the Employee Change Form - Dental Select online is a straightforward process that allows users to update their personal and coverage information effectively. This guide will provide clear steps to help you complete the form accurately and efficiently.

Follow the steps to complete the form seamlessly.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. Fill in the employer's full name and address, along with the group number and subgroup/department number. Make sure to enter the effective date in MM/DD/YY format.
3. Provide the subscriber's name and their social security number or member number.
4. Select personal information changes, such as changing your name or address. Enter the old employee name and new employee name, new address, city, state, zip code, and phone number.
5. Confirm your coverage selection. Check all applicable plans, ensuring you review the options available through your employer. Note any potential premium adjustments.
6. Indicate the reason for the change. Select the applicable status, including rehire, loss or gain of coverage, employment status changes, or any other relevant reason. Provide dates as specified.
7. List individuals for whom you are changing or terminating coverage. Include details like names, genders, social security numbers, and dates of birth for each individual.
8. Complete the authorization of change section. Both the employer and subscriber must sign the form to validate the changes.
9. After completing all sections, save your changes. You can download, print, or share the form as needed to submit it to Dental Select.

Complete your Employee Change Form - Dental Select online today for a smooth update process.