Healthplex Enrollment Form PDF Details

Navigating the complex world of dental insurance enrollment can be a daunting task, but understanding the Healthplex Enrollment Form is a significant first step in gaining access to dental care coverage. This form serves as a gateway for individuals seeking dental insurance through DENTCARE Delivery Systems, Inc., International Healthcare Services, Inc., Healthplex Insurance Company, or Healthplex, Inc. The process begins with personal details, requiring the employee's name, identification, and contact information, followed by employment and insurance details that include the employer's name, group number, and any existing dental coverage. Importantly, the form also delves into the selection of dental plans, offering a range of options from CapDent Plus Ultra to High Enhanced Option, catering to diverse needs and preferences. Each plan is designed to cover individual employees, two-party enrollments, or families, with specific attention to dependents, where it's crucial to note any over the age of 18 may require additional documentation. Unique to managed care plans, enrollees must select a primary care family dentist from a specified directory, emphasizing the focus on personalized dental care. Broker information and a declaration against false information underpin the form's completion, binding the enrollee to honesty and accuracy. Located in Uniondale, New York, Healthplex makes this vital form accessible through their website, simplifying the process of enrolling in comprehensive dental care coverage.

QuestionAnswer
Form NameHealthplex Enrollment Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesenrollment healthplex dental, member activate, enrollment forms, healthplex enrollment online

Form Preview Example

Dental Plan Enrollment Form

FOR DENTAL PLANS BY DENTCARE DELIVERY SYSTEMS, INC., INTERNATIONAL HEALTHCARE SERVICES, INC.,

HEALTHPLEX INSURANCE COMPANY, OR HEALTHPLEX, INC.

Employee Information

Last Name

 

 

 

 

First Name

 

 

M.I.

SSN/ID Number

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

City

 

State

Zip Code

 

 

 

 

 

 

 

 

 

 

 

Home Phone

 

 

 

 

Work Phone

 

 

Gender

 

D.O.B.

 

 

 

 

 

 

 

 

 

 

 

Employer Name/Group

 

 

 

 

 

Group Number

Effective Date

Date of Hire

 

 

 

 

 

 

 

 

 

 

Other Dental Coverage:

 

NO

 

YES

Name of Other Plan (if applicable):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Group Plan Selection

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CapDent Plus Ultra

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Comprehensive Voluntary

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CapDent New York

 

CapDent Plus New York

 

Preferred Choice Plan

Omni PPO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Low Option

 

 

 

 

 

 

 

 

 

 

 

 

 

CapDent Select

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medium Option

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CapDent Plus New Jersey

 

 

 

 

Healthplex

 

 

 

 

 

 

 

CapDent New Jersey

 

 

 

 

 

 

 

 

 

 

 

 

 

 

High Option

 

 

 

 

 

 

 

 

 

 

 

 

 

CapDent Select Plus

Insurance Company Plan

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Primary

EPO

 

 

 

 

 

 

 

 

High Enhanced Option

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Coverage Selected

 

 

 

 

Dental Selection

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dentist Name

 

 

 

Dentist Site Code

 

For Managed Care Plans - Please choose one Primary Care

 

 

 

 

 

 

 

Family

 

 

 

 

 

 

 

 

Dentist from the CapDent Directory - One Per Family

 

 

 

 

 

 

 

 

 

 

 

 

Single

Two Party

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dependents To Be Covered (Spouse, Domestic Partner & unmarried dependent children) * If your child is over the age of 18, you must submit student documentation.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last Name, First Name

 

 

 

 

 

 

 

 

 

M/F

Spouse/D.P.

Son

Dtr

 

D.O.B.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last Name, First Name

 

 

 

 

 

 

 

 

 

M/F

Spouse/D.P.

Son

Dtr

 

D.O.B.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last Name, First Name

 

 

 

 

 

 

 

 

 

M/F

Spouse/D.P.

Son

Dtr

 

D.O.B.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last Name, First Name

 

 

 

 

 

 

 

 

 

M/F

Spouse/D.P.

Son

Dtr

 

D.O.B.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*Last Name, First Name

 

 

 

 

 

 

 

 

 

M/F

Spouse/D.P.

Son

Dtr

 

D.O.B.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*Last Name, First Name

 

 

 

 

 

 

 

 

 

M/F

Spouse/D.P.

Son

Dtr

 

D.O.B.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*There is an additional monthly premium of $10.00 for each family member in excess of five (5).

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature

 

 

 

 

 

 

 

 

 

 

 

 

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Broker Information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Broker Name

 

 

 

 

 

 

 

 

 

 

SSN/Tax ID #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Any person who includes any false or misleading information on an application for an Insurance Policy is subject to criminal and civil penalties.

333 Earle Ovington Blvd., Suite 300 Uniondale, New York 11553-3608

www.healthplex.com

P 800-468-0608 F 516-227-0582

 

F-2206

Print Date 3-4-2011

"PLEASE PRINT OR TYPE ALL INFORMATION"