Delta dental enrollment change form 2026

1. Click ‘Get Form’ to open the delta dental enrollment change form in the editor.
2. Begin by selecting the appropriate checkbox for your request: New Enrollment, Status Change, Address Change, or Termination. Specify if you are enrolling for Dental Only, Vision Only, or both.
3. Fill in your Social Security Number and Group Number. Enter the effective date of the change in Month/Day/Year format.
4. Complete your personal information including Group Name, Subscriber’s Identifier (if applicable), Last Name, First Name, Middle Initial, Street Address, City, State, ZIP Code, and Email.
5. Indicate your Marital Status and Sex. Provide your Date of Birth and Date of Hire.
6. If applicable, mark any medical conditions that may entitle you to additional benefits and provide relevant dates.
7. In the Coverage Changes section, check all boxes that apply to your situation regarding dependent changes or coverage modifications.
8. List all members affected by this change in the designated area. Include their names and relevant details such as EBD Codes and Onset Dates.
9. Review the Authorization section carefully before signing. Ensure all information is accurate before submitting.

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