Direct Compensation Enrollment Form

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Direct Compensation Enrollment Form

  1. 1. RELATION TO EMPLOYEE SPOUSE CHILD CHILD RELATION TO EMPLOYEE CHILD CHILD CHILD LAST NAME FIRST NAME (MI) DATE OF BIRTH M / D / Y DATE OF BIRTH M / D / Y SEX (M/F) SEX (M/F) DDS # (DHMO ONLY) LAST NAME FIRST NAME (MI) LAST NAME HOME ADDRESS (Street and Apartment) CITY, STATE, ZIP CODE NAME OF DENTIST (IF SELECTING DHMO OPTION) DENTIST # HIRE DATE DATE OF MARRIAGE MARITAL STATUS HOME TELEPHONE SOCIAL SECURITY NUMBER EMPLOYERFIRST NAME INITIAL DATE OF BIRTH SEX (M/F) CHECK ONE zDHMO z PPO/EPO z INDEMNITY CHECK ONE z NEW ENROLLMENT z CHANGE PROVIDER z ADDRESS CHANGE z NAME CHANGE z DELETE DEPENDENTS z ADD DEPENDENTS ADMIN. PLAN EFF. DATE Does Spouse have a dental plan? Yes z No z With whom? _______________________________ if answer is “Yes” are dependents enrolled under spouse’s plan? Yes z No z z Please check if you would like to receive a copy of the “Consent for Use and Disclosure of Health Information” form. I UNDERSTAND THAT ONCE I HAVE CHOSEN THIS PLAN, I CANNOT CHANGE UNTIL THE NEXT OPEN ENROLLMENT PERIOD. I AGREE, THAT IF I OR MY DEPENDENTS SEEK SERVICES WHEN NOT ELIGIBLE FOR COVERAGE, THAT I WILL PAY THE DENTISTS USUAL FEE. Employee’s/Subscriber’s Signature Date Signed PUD-4124 DDS # (DHMO ONLY) EMPLOYER’S USE ONLY GROUP # Enrollment/Change Form

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