Forms
Helpful forms for managing benefits
Incorrect information could cause your employee’s Protected Health Information to be viewed by another party.
*Implementation Credits
Note: Implementation credits are not available in all states or jurisdictions. Check with your sales representative to determine availability.
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
Spanish Enrollment Form
(Not for use in CA, FL, HI, LA, MD, MI, MT, NJ, TN, VA, WA and WI.) - DHMO Plans
Spanish Enrollment Form
(Not for use in CA, MD, MI, NJ and TX.) - USERRA Enrollment Forms
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 CA FFS Enrollment Form
(For California Residents with a FFS plan.) 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 CA DHMO Enrollment Form
(For California Residents with a DHMO plan.) 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.
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.
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 Dental
Attn: Membership Services, DP1H
4401 Deer Path Road
Harrisburg, PA 17110
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.
Connect with United Concordia Dental