Dental Enrollment Form.pdf

ALL SECTIONS MUST BE COMPLETED FOR APPLICATION TO BE PROCESSED.
ENROLLMENT FORM
SOCIAL SECURITY NUMBER
GROUP NUMBER
EMPLOYER AND LOCATION
EMPLOYEE LAST NAME
FIRST NAME
MI
EMPLOYEE’S HOME PHONE
HOME ADDRESS
APT#
GENDER
DATE OF BIRTH
CITY
STATE
ZIP CODE
COUNTY IN WHICH YOU RESIDE
MARITAL STATUS:
EMPLOYMENT DATE
EFFECTIVE DATE
APPLICATION FOR DENTAL COVERAGE
COMPLETE THE FOLLOWING INFORMATION FOR EACH DEPENDENT TO BE COVERED BY THE PLAN
NAME – IF LAST NAME DIFFERENT FROM ABOVE INDICATE LAST NAME
RELATIONSHIP
GENDER
BIRTH DATE
WILL YOU OR ANY DEPENDENT HAVE OTHER DENTAL INSURANCE COVERAGE?
REFUSAL/WAIVER – COMPLETE ONLY IF YOU ARE DECLINING COVERAGE FOR YOURSELF OR ANY DEPENDENT
I DECLINE COVERAGE FOR:
REASON FOR REFUSAL:
On behalf of myself and any dependants listed above, I hereby apply for coverage under the Master Group Policy/Contract issued to my employer
by Dental Care Plus, Inc.
I authorize my employer to deduct the necessary contributions, if any, from my wages or salary,
I hereby waive the dentist-patient privilege and authorize any dentist or other provider of dental services to give Dental Care Plus, Inc., its agents
and representatives any information concerning the claims for reimbursement for covered services of any person included under such coverage,
To the best of my knowledge, the above information is complete, true, and correct.
PLEASE SIGN WHETHER YOU ARE ACCEPTING OR DECLINING COVERAGE
EMPLOYEE SIGNATURE DATE_
Fraud Notice - Ohio Residents Only: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits
an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
Fraud Notice – Kentucky Residents Only: Any person who knowingly and with intent to defraud any insurance company or other person files an
application for insurance containing any materially false information or conceals for the purpose of misleading, information concerning any fact
material thereto commits a fraudulent act, which is a crime.
Fraud Notice – Indiana Residents Only: Any person who knowingly and with intent to defraud an insurer files an application for insurance
containing any false, incomplete, or misleading information commits a felony.
DCP 400/DSP 400
Rev. 4/25/12
Dental Care Plus, Inc.
100 Crowne Point Place • Cincinnati, OH 45241
Phone (513) 554-1100 • 1-800-367-9466