Forms: Dental

Below are forms for the Dental plan. For the forms pertaining to more than one benefit plan, please refer to Human Resources Benefits Forms Page.

Newly eligible faculty & staff may conviently elect to or waive healthcare coverage using the eBenefits, HRIS Self Service module.
Benefit Enrollment and Change ( PDF)	After hire, use this form to enroll in the health plan or change the coverage of a spouse or dependent child as a result of a change in family or employment status. Must be submitted within 31 days from the date of the qualifying event.
Same Gender Domestic Partner Relationship Declaration Form ( PDF)	This form is used to declare a same gender domestic partner relationship.
Same Gender Domestic Partner Relationship Termination Form ( PDF)	This form is used to declare a termination of a same gender domestic partner relationship.
Name & Address Change ( PDF)	Use this form to change name and or address with insurance company(s)
Retiree Dental ( PDF)	Dental enrollment form for Retiree participants
COBRA Dental ( PDF)	Dental enrollment form for COBRA participants
Blue Cross/Blue Shield Dental Claim Form ( PDF)	To submit, with dental service receipts, to your BC/BS dental plan provider.
Leave of Absence Dental Enrollment and Policy Change Form ( PDF)	For Leave of Absence participants, dental care enrollment and changes
Blue Cross/Blue Shield Statement of Dental Condition Form ( PDF)	To submit with your Dental Enrollment form if you are trying to get into BC/BS during Open Enrollment for yourself or any member of your family that does not have dental coverage. This form must be filled out by a dentist and returned with your enrollment form by the Open Enrollment deadline.
Visiting Scholar Dental Enrollment Form ( PDF)	Specific Dental enrollment form for Visiting Scholars only who are hired in October and November 2006. Not applicable for 2007
Benefit Plan Withdrawal Form ( PDF)	Use this form to drop specified Benefits.