United concordia dental enrollment form 2025

1. Click ‘Get Form’ to open the united concordia dental enrollment form in the editor.
2. Begin with Section A, where you will enter your personal information as the sponsor. Fill in your name, Social Security Number, date of birth, and contact details including home address and phone number.
3. In Section B, list all family members you wish to enroll. Include their names, dates of birth, and indicate if any are geographically separated. If you have more than four family members, attach an additional sheet.
4. Proceed to Section C to disclose any other dental coverage you or your family members may have. If applicable, provide the insurance company name and policy number.
5. In Section E, specify your initial payment method. You can choose between credit card or check/money order options. Ensure that all required fields are completed accurately.
6. Finally, sign and date the form in Section F to authorize your application for coverage. Make sure to submit both sides of the form if it is two-sided.

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