Forms

Helpful forms for managing benefits

Incorrect information could cause your employee’s Protected Health Information to be viewed by another party.

 

Enrollment Forms – Group Dental Plans

Please select and complete the appropriate form(s) below, then send your enrollment information by secure form submission, fax or mail.

  • PPO Plans
    Choose the state where your group is headquartered:

    Spanish Enrollment Form PDF icon (Not for use in CA, FL, HI, LA, MD, MI, MT, NJ, TN, VA, WA and WI.)

  • DHMO Plans
    Choose the state where your employee resides:

    Spanish Enrollment Form PDF icon (Not for use in CA, MD, MI, NJ and TX.)

  • USERRA Enrollment Form
    Use this for employees who serve temporarily in the uniformed services and wish to continue coverage for up to 24 months during deployment or to reinstate coverage after deployment.
    USERRA Enrollment Form PDF icon

Ready to submit?

Access one of the 3 tabs below for sending enrollment by secure form, fax or mail. Depending on your request, your enrollment updates may take up to 10 business days to process.

Step 1 - Verify you have the appropriate enrollment forms and files ready.

Step 2 - Send enrollment files using our secure form.

Send Enrollment

Step 1 - Verify you have the appropriate enrollment forms ready.

Step 2 - Fax completed forms or enrollment changes to 1-800-329-9093.

Step 1 - Verify you have the appropriate enrollment forms ready.

Step 2 - Mail completed forms or enrollment changes to:

  • United Concordia Companies, Inc.
    P.O. Box 69405
    Harrisburg, PA 17106-9405

Claim Forms

Your employees may need claim forms if they plan to visit a non-network dentist (network dentists will submit claims for members). You can view the forms here.

 

Referral Forms

If your employees have a DHMO plan, their general dentist will complete a referral form if they need to see a specialist. You can view the forms here.

 

Other useful information

Read about online tools for employers

See how employees’ improved oral health can benefit your bottom line