Anthem dental membership enrollment form 2026

1. Click ‘Get Form’ to open the anthem dental membership enrollment form in the editor.
2. Begin with Part A, where you will enter your personal information. Fill in your last name, first name, middle initial, gender, marital status, address, social security number, date of birth, and phone numbers.
3. Move to Part B to select your coverage type. Choose one option that best fits your needs: Employee Only, No Coverage, Employee and Spouse, Employee and Dependent Child(ren), or Family. If applicable, complete the multiple plan options offered section.
4. In Part C, provide details about your dependents. For each dependent, include their relationship to you, full name, gender, date of birth, and whether they are a full-time student or unmarried.
5. Proceed to Part D for your signature. Indicate if you or your dependents have other dental coverage and provide necessary details. Sign and date the form to confirm your enrollment.
6. Finally, if applicable, ensure that Part E is completed by your employer with all required group enrollment information before submitting the form.

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