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Member Forms

Authorization Form for Release of Health and Payment Information (PDF, 2 pages, 21kb)
Certification of Handicapped Child's Dependency Status (PDF, 1 page, 13kb)
COBRA Application (PDF, 1 page, 59kb)
Coordination of Benefits Form (DOCX, 1 page, 708kb)
Dentist Nomination Form (PDF, 1 page, 17kb)
Integrated Oral Health Option Qualification Form (for diagnoses of diabetes, pregnancy, or heart disease) (PDF, 1 pages, 113kb)
Oral Health Enhancement Option Qualification Form (for diagnoses of periodontal disease) (PDF, 1 pages, 16kb)
Request for External Review (Appeal Form 1B) (PDF, 1 page, 59kb)
Request for Internal Review (Appeal Form 1A) (PDF, 1 page, 86kb)
Student Documentation Verification Form (PDF, 1 page, 126kb)

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Employer Forms

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)
Change Transmittal Form (PDF, 2 pages, 127kb)
Eligibility Enrollment Change Form (PDF, 2 pages, 22kb)
Certification of Handicapped Child's Dependency Status (PDF, 1 page, 13kb)

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Dentist Forms

Authorization Form for Release of Health and Payment Information (PDF, 2 pages, 21kb)
Certification of Handicapped Child's Dependency Status (PDF, 1 page, 13kb)
Dentist Change of Address Form (PDF, 7 pages, 248kb)
EFT Paper Enrollment Form (PDF, 3 pages, 100kb)
NPI Form (PDF, 2 pages, 82kb)
Integrated Oral Health Option Qualification Form (for diagnoses of diabetes, pregnancy, or heart disease) (PDF, 1 pages, 113kb)
Oral Health Enhancement Option Qualification Form (for diagnoses of periodontal disease) (PDF, 1 pages, 16kb)
Request for External Review (Appeal Form 1B) (PDF, 1 page, 59kb)
Request for Internal Review (Appeal Form 1A) (PDF, 1 page, 86kb)
Student Documentation Verification Form (PDF, 1 page, 126kb)
W-9 (PDF, 7 pages, 235kb)

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Broker Forms

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)
Small Business Program Group Dental Application (PDF, 3 pages, 503kb)
Small Business Program Employee Enrollment Change Form (PDF, 1 page, 99kb)

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Employer Forms

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)
Change Transmittal Form (PDF, 2 pages, 127kb)
Eligibility Enrollment Change Form (PDF, 2 pages, 22kb)
Certification of Handicapped Child's Dependency Status (PDF, 1 page, 13kb)

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