Dental/Vision Insurance

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Dental Provider Directory
Dental Claim Forms
Vision Insurance Claim Form
State Variations

Dental Claim Forms
 
Dental Claim Statement for employee and dentist to complete
Dental Claim Statement for New York School Trust

Vision Insurance Claim Form
 
Group Accounts Only: Claim form for Vision benefits
Vision Claim Statement for New York School Trust

State Variations
 

CO - Colorado

CO Notice of Your Right to Continue Group Dental Coverage. Notice to employees about continuing coverage if family or employee status changes
CO Form for employee and employer to complete to Continue group Dental Coverage if coverage terminates due to family or employee status change

CT - Connecticut

CT Notice of Your Right to Continue Your Medical and Dental Coverage. Notice to employees about continuing coverage if family or employee status changes
CT Form for employee to complete to continue Group Medical and Dental Coverage if coverage terminates due to family or employee status change

ME - Maine

ME Third Party Notice. Employees can use this form if they wish a third party (relative) to be notified if coverage is terminated
ME Notice of Admin Review. If reinstatement of coverage is denied due to organic brain disease, this notice says a third party (relative, attorney) can be notified about the denial and right to appeal.

MA - Massachusetts

MA Continuance for Medical and/or Dental. Employees should use this form to request continuance of dental insurance.
MA Notice of Your Right to Continue Your Group Medical and Dental Coverage for firms with 20 or more employees. Notice to be distributed to employees.
MA Notice of Your Right to Continue Your Group Medical and Dental Coverage for firms with 2-19 employees. Notice to be distributed to employees.
MA Notice to Massachusetts Employers. Employers required to notify employees if medical or dental coverage will be cancelled and not replaced by self-insured or fully-insured plan

MI - Michigan

(Indemnity Plan) MI Disclosure of Information – Group Dental Plan: This form should be used with Certificate of Insurance to clarify and provide additional information about Dental Indemnity benefits
(Preferred Provider Organization Plan) MI Disclosure of Information – Group Dental Plan: This form should be used with Certificate of Insurance to clarify and provide additional information about Dental PPO plan benefits

MN - Minnesota

MN Notice of Continuation of Group Life, Medical and Dental Coverage:Notice to employees about coverage continuation should their family or employment status change
MN Continuance of Medical/Dental/Life:form for both employers and employees to complete to continue coverage if family or employee status changes.

MO - Missouri

MO Notice of Your Right to Continue Medical and/or Dental Coverage. Notice to employees about coverage continuation if their family or employment status changes.

NV - Nevada

(Indemnity Plan) NV Disclosure of Information – Group Dental Plan. This form should be used with Certificate of Insurance to clarify and provide additional information about Dental Indemnity benefits.
(Preferred Provider Organization Plan) NV Disclosure of Information – Group Dental Plan. This form should be used with Certificate of Insurance to clarify and provide additional information about Dental PPO plan benefits.
(Preferred Provider Organization Plan provided by Diversified Dental Services, Inc.) NV Disclosure Information - Group Dental Plan. This form should be used with Certificate of Insurance to clarify and provide additional information about Dental PPO Plan benefits when the PPO is provided by Diversified Dental Services, Inc.

NY - New York

NY Notice of Your Right to Continue Group Coverage: Notice to employees about coverage continuation should their family or employment status change.

NC - North Carolina

NC Insurance Fiduciary Notice to employers about their responsibilities

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