Forms and documents Alaska

Forms and documents

Plan confirmation forms for groups 1-50

• 1-50 Group Plan Confirmation Form

Group resources

• Group Application 1-50
• Group Size Determination Form

Benefit Summaries

• Access Benefit Summaries (SOBs) for groups 1-50

Individual resources

• Alaska Individual and family dental plans brochure

Enrollment application & change of information forms

• Dental
• Dental (Español)
• Domestic partnership documentation for qualified plans
• Authorization Agreement Form (EFT) – Group

Privacy

• Authorize Delta Dental to use/disclose information about a member - Instructions
• Authorize Provider or Hospital to use/disclose information to Delta Dental - Form

Claims

• Claims form – Log in to Member dashboard to access claim form
• Dental Explanation Of Benefits (EOB) sample

Coordination of Benefits

• Coordination of Benefits