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877-605-3229 Medical
888-374-8906 Dental
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888-374-8910

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877-277-7075

Samples & Forms

Samples

• Dental Explanation of Benefits (EOB) (PDF)
• Medical Explanation of Benefits (EOB) (PDF)

Forms

Claims

• Prescription Drug Claim Form for Major Medical Plans (PDF)
• Prescription Drug Claim Form for Med Impact Plans (PDF)
• Prescription Compound Drug Claim Form (PDF)

Declination

• Declination of Dental (PDF)
• Declination of Medical (PDF)

Enrollment

• Medical & Dental Enrollment (PDF)
• Medical Only Enrollment (PDF)
• Dental Only Enrollment (PDF)
• Health Statement for groups 2-9 (PDF)
• Health Statement for groups 10-50 (PDF)
• Affidavit of Domestic Partnership for qualified plans (PDF)

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• Authorize ODS to use/disclose information about a member (PDF)  - Instructions

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Medical insurance products provided by ODS Health Plan, Inc. Dental insurance products provided by Oregon Dental Service, doing business as Delta Dental of Alaska.