Vision Forms

DeltaVision® is now available for groups of up to 300 employees.

Group application

Employee enrollment form

Dental Forms

Small Groups (Fewer than 100 employees)

Small group subscriber enrollment/change form

Website authorization form for pool-rated groups

Large Groups (100+ employees)

Large group subscriber enrollment/change form

Website authorization form for experience-rated and self-funded groups

Small and Large Groups

Dental claim form*

Plan sponsor disclosure designee form for risk groups

Plan sponsor disclosure designee form for ASO groups

ASO contract addendum for HIPAA privacy and security

Healthy Smile, Healthy You® Enrollment form

Automatic bank draft authorization for risk groups

Group Information Change Request Form