Employers

 

Forms

 

Employee Enrollments - Fill in and/or Download Forms

Employee Enrollment Form - Employee enrollment form for Group Plans.

Employee Enrollment Form (Spanish) - Employee enrollment form for Group Plans.

Group Applications / Downloadable Forms

All Plans Application - Contributory / Voluntary Group Dental Plan Application.

New Group Check List

Group Portal Sign-Up Sheet

Change Forms

Employee Change Form - Form to submit any changes to your group plan (name, additions, cancellations, etc.).

Group Change Form - Form to submit any changes to your group plan (name, additions, cancellations, etc.).

 

Multiple Subscriber Cancel Form - Form for cancelling multiple members.

 

Miscellaneous

How to Read Your Statement

 

Helpful Benefit Hints - Get the most out of your dental plan.

Supply Request Form

ACE Privacy Policy in Spanish

ACE Privacy Policy

Dental Claim Form

 

 

Vision

EyeMed Vision Out-of-Network Claim Form

  

Online Forms

Request Information

Request Kit

 

FAQ’s

 

How do I add or cancel an employee?

You may add or cancel an employee during open enrollment, or within 31 days of a qualifying event: marriage, divorce or legal separation, birth of a child or adoption of a child, loss of employment, new employment, or death of insured.

All additions and cancellations will be effective on the first of the month following any waiting periods.

When cancelling an employee, the effective date of change must be the final day of the last covered month. A member can be cancelled back to the 1^st of the current month only when Dental Select receives the cancellation notice on or before the 15^th of that month. If Dental Select receives the cancellation notice after the 15^th of the month, member will be cancelled the last day of that month. As long as no claims have been processed, a member may be cancelled back two (2) months.

When will ID Cards arrive? How do I order replacement ID Cards?

ID Cards will arrive approximately 7 – 10 days from the time Dental Select receives the enrollment or change form.

Two ID cards are mailed in a certificate booklet format. Please instruct employees to bring one card with them to their appointment so that the provider is aware of their dental plan and can discount the charges accordingly. The other card is included for their convenience.

If an employee loses their ID card, please instruct them to contact Member Services at 1-800-999-9789.

How do I request supplies?

You can request supplies for your group by:

• Calling the Supplies Department at (800) 999-9789, or
• Fax a completed supply request form located in the above Forms section.

 

How can I obtain additional information on HIPAA?

Dental Select is HIPAA compliant. For more information on HIPAA visit the following websites:

US Department of Health & Human Services

http://www.dhhs.gov/ocr/hipaa/

Center for Medicaid Services

www.cms.hhs.gov/hipaa/

 

 

 

 

Forms

 

Employee Enrollments - Fill in and/or Download Forms

Employee Enrollment Form - Employee enrollment form for Group Plans.

Employee Enrollment Form (Spanish) - Employee enrollment form for Group Plans.

 

Group Applications / Downloadable Forms

All Plans Application - Contributory / Voluntary Group Dental Plan Application

New Group Check List

Group Portal Sign-Up Sheet

Change Forms

Employee Change Form - Form to submit any changes to your group plan (name, additions, cancellations, etc.).

Group Change Form - Form to submit any changes to your group plan (name, additions, cancellations, etc.).

 

Multiple Subscriber Cancel Form - Form for cancelling multiple members.

 

Miscellaneous

 

How to Read Your Statement

 

Helpful Benefit Hints - Get the most out of your dental plan.

 

Supply Request Form

ACE Privacy Policy in Spanish

ACE Privacy Policy

Dental Claim Form

 

Authorization Form

 

 

Vision

EyeMed Vision Out-of-Network Claim Form

 

FAQ’s

 

How do I add or cancel an employee?

You may add or cancel an employee during open enrollment, or within 31 days of a qualifying event: marriage, divorce or legal separation, birth of a child or adoption of a child, loss of employment, new employment, or death of insured.

All additions and cancellations will be effective on the first of the month following any waiting periods.

When cancelling an employee, the effective date of change must be the final day of the last covered month. A member can be cancelled back to the 1^st of the current month only when Dental Select receives the cancellation notice on or before the 15^th of that month. If Dental Select receives the cancellation notice after the 15^th of the month, member will be cancelled the last day of that month. As long as no claims have been processed, a member may be cancelled back two (2) months.

When will ID Cards arrive? How do I order replacement ID Cards?

ID Cards will arrive approximately 7 – 10 days from the time Dental Select receives the enrollment or change form.

Two ID cards are mailed in a certificate booklet format. Please instruct employees to bring one card with them to their appointment so that the provider is aware of their dental plan and can discount the charges accordingly. The other card is included for their convenience.

If an employee loses their ID card, please instruct them to contact Member Services at 1-800-999-9789.

How do I request supplies?

You can request supplies for your group by:

• Calling the Supplies Department at (800) 999-9789, or
• Fax a completed supply request form located in the above Forms section.

How can I obtain additional information on HIPAA?

Dental Select is HIPAA compliant. For more information on HIPAA visit the following websites:

US Department of Health & Human Services

http://www.dhhs.gov/ocr/hipaa/

Center for Medicaid Services

www.cms.hhs.gov/hipaa/

 

 

 

Forms

 

Employee Enrollments - Fill in and/or Download Forms

Employee Enrollment Form - Employee enrollment form for Group Plans.

Employee Enrollment Form (Spanish) - Employee enrollment form for Group Plans.

 

Group Applications / Downloadable Forms

All Plans Application - Contributory / Voluntary Group Dental Plan Application

New Group Check List

Group Portal Sign-Up Sheet

 

Change Forms

Employee Change Form - Form to submit any changes to your employee's plan (name, additions, cancellations, etc.).

 

Group Change Form - Form to submit any changes to your group plan (name, additions, cancellations, etc.).

 

Multiple Subscriber Cancel Form - Form for cancelling multiple members.

 

 

Miscellaneous

How to Read Your Statement

 

Helpful Benefit Hints - Get the most out of your dental plan.

 

Supply Request Form

ACE Privacy Policy in Spanish

ACE Privacy Policy

Dental Claim Form

 

Authorization Form

 

 

 

Vision

EyeMed Vision Out-of-Network Claim Form

 

 

 

FAQ’s

 

How do I add or cancel an employee?

You may add or cancel an employee during open enrollment, or within 31 days of a qualifying event: marriage, divorce or legal separation, birth of a child or adoption of a child, loss of employment, new employment, or death of insured.

All additions and cancellations will be effective on the first of the month following any waiting periods.

When cancelling an employee, the effective date of change must be the final day of the last covered month. A member can be cancelled back to the 1^st of the current month only when Dental Select receives the cancellation notice on or before the 15^th of that month. If Dental Select receives the cancellation notice after the 15^th of the month, member will be cancelled the last day of that month. As long as no claims have been processed, a member may be cancelled back two (2) months.

When will ID Cards arrive? How do I order replacement ID Cards?

ID Cards will arrive approximately 7 – 10 days from the time Dental Select receives the enrollment or change form.

Two ID cards are mailed in a certificate booklet format. Please instruct employees to bring one card with them to their appointment so that the provider is aware of their dental plan and can discount the charges accordingly. The other card is included for their convenience.

If an employee loses their ID card, please instruct them to contact Member Services at 1-800-999-9789.

How do I request supplies?

You can request supplies for your group by:

• Calling the Supplies Department at (800) 999-9789, or
• Fax a completed supply request form located in the above Forms section.

How can I obtain additional information on HIPAA?

Dental Select is HIPAA compliant. For more information on HIPAA visit the following websites:

US Department of Health & Human Services

http://www.dhhs.gov/ocr/hipaa/

Center for Medicaid Services

www.cms.hhs.gov/hipaa/