Forms

What form should I use and when should I use it?

Member Enrollment Form

Member Claim Form

Member Notice of Change Form

Member Expenses Summary Form

Authorization to Release Medical Information Form

Authorization To Release Information To Subscriber (Use this if you want to get access to your spouse or dependents' claim information online)

Domestic Partner Affidavit

Standardized Health Form

Employer Application (Health Only)

Employer Application (with Delta Dental)

Conversion Coverage Information

Automated Premium Payment (ACH) Form

Signature Plan Member Certificate

Traditional Plan Member Certificate

Standard Plan Member Certificate

ATTENTION PRODUCERS: Please use this enrollment checklist to ensure that your employer group is set up correctly and in time for their effective date.