Useful client forms for enrollment and claims
Groups may need to access these forms to complete enrollment for their employees. Please select the appropriate state from the drop-downs below. Fax completed forms to 1-800-329-9093 or mail enrollment forms to:
United Concordia Dental Companies, Inc.
P. O. Box 69405
Harrisburg, PA 17106-9405
- PPO Plans
Choose the state where your group is headquartered:
Spanish Enrollment Form (Not for use in CA, FL, HI, LA, MD, MI, MN, NJ, TN, VA, WA and WI.)
- DHMO Plans
Choose the state where your employee resides:
Spanish Enrollment Form (Not for use in CA, FL, 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
Members may need claim forms if they plan to visit a non-network dentist (network dentists will submit claims for members). They can get the forms under Already a Member, or you can view the claim forms here.
With a DHMO plan, members’ general dentists will need to complete a referral form if the member needs to see a specialist. Members can get a referral form under Already a Member, or you can view the referral forms here.