FORMS & APPLICATIONS

Small business (Fewer than 100 employees) 

• Small group application
• Small group subscriber enrollment/change form
• Website authorization form for pool-rated groups

Large business (100+ Employees) 

• Large group subscriber enrollment/change form
• Website authorization form for fully-insured groups
• Website authorization form for self-insured groups

Other Forms

• ASO contract addendum for HIPAA privacy and security
• Healthy Smile, Healthy You® enrollment form
• Healthy Smile, Healthy You® enrollment form — Spanish
• Group Information Change Request Form
• Automatic bank draft authorization for risk groups
• Automatic bank draft authorization of weekly claims and monthly admin fees for self-insured groups
• Automatic bank draft authorization of monthly claims and monthly admin fees for self-insured groups

FLYERS & OTHER RESOURCES

Benefit Flyers & Brochures

• Healthy Smile, Healthy You®
• MaxOver™
• Prevention First
• Right Start 4 Kids®
• Special Health Care Needs
• Delta Dental — Virtual Visits
• Amplifon Hearing Discount
• Special Health Care Needs Benefits for self-insured groups
• Special Health Care Needs Benefit for fully-insured groups

Other Resources

• Employer website quick reference guide
• Mobile app flyer
• Portal reports guide for employers
• Online Billing Guide
• Online Billing FAQ
• ASC Weekly Claims Invoice FAQ
• Video: Quoting tool
• Video: Account structure
• Video: Enrollment
• Video: Billing
• Voluntary dental benefits resources
• Video: Why are dental benefits important?

VISION RESOURCES

Forms

• HIPAA Form 14a — fully-insured groups
• HIPAA Form 14b — self-insured groups

Other Vision Resources

• DeltaVision® plan comparison sheet
• DeltaVision network flyer
• KidsCare flyer
• LightCare flyer
• EasyOptions flyer
• Medical eye care flyer
• Laser eye surgery flyer
• Blue light flyer
• Diabetic eyecare plus program flyer

EMPLOYEE RESOURCES

For all employee-related resources, visit our member resources page.