skip to main content
Client Insurance Forms - Producers – United Concordia Dental

Client Insurance Forms 

Useful client forms for enrollment and claims

 

Enrollment Forms – Group Dental Plans

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

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

  • DHMO Plans

    Spanish Enrollment Form PDF icon (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 PDF icon

 

Claim Forms

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.

 

Referral Forms

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.

 

Other useful information for producers

Get a quote today

Find out how to get appointed

Review your commission history

Contact your local sales representative