Delta dental small business program enrollment change fillable form 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your company/group name at the top of the form. This identifies your organization within the Delta Dental system.
3. Select your Delta Dental plan by checking either 'Delta Dental PPOsm' or 'DeltaCare®USA'. Ensure you have your employer number ready for accurate processing.
4. Indicate the reason for addition/change by checking the appropriate box. If applicable, provide additional details such as dates for new hires or dependent changes.
5. Fill in enrollee information including name, social security number, gender, and mailing address. This section is crucial for identifying the primary enrollee.
6. List any dependents to be enrolled or deleted. Include their names, dates of birth, and check if they are full-time students or disabled if applicable.
7. For DeltaCare USA enrollees, complete the provider choice section with dental office ID and name.
8. Finally, sign and date the form at the bottom to validate your submission. Remember that this form must be submitted by the 25th of the month prior to your desired effective date.

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