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.
Question | Answer |
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Form Name | Healthplex Enrollment Form |
Form Length | 1 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 15 sec |
Other names | enrollment healthplex dental, member activate, enrollment forms, healthplex enrollment online |
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 |
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First Name |
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M.I. |
SSN/ID Number |
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Address |
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City |
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Zip Code |
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Home Phone |
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Work Phone |
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Gender |
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D.O.B. |
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Employer Name/Group |
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Group Number |
Effective Date |
Date of Hire |
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Other Dental Coverage: |
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NO |
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YES |
Name of Other Plan (if applicable): |
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Group Plan Selection
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CapDent Plus Ultra |
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Comprehensive Voluntary |
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CapDent New York |
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CapDent Plus New York |
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Preferred Choice Plan |
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Omni PPO |
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Low Option |
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CapDent Select |
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Medium Option |
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CapDent Plus New Jersey |
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Healthplex |
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CapDent New Jersey |
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High Option |
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CapDent Select Plus |
Insurance Company Plan |
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Primary |
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EPO |
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High Enhanced Option |
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Coverage Selected |
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Dental Selection |
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Dentist Name |
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Dentist Site Code |
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For Managed Care Plans - Please choose one Primary Care |
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Family |
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Dentist from the CapDent Directory - One Per Family |
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Single |
Two Party |
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Dependents To Be Covered (Spouse, Domestic Partner & unmarried dependent children) * If your child is over the age of 18, you must submit student documentation. |
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Last Name, First Name |
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M/F |
Spouse/D.P. |
Son |
Dtr |
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D.O.B. |
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Last Name, First Name |
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M/F |
Spouse/D.P. |
Son |
Dtr |
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D.O.B. |
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Last Name, First Name |
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M/F |
Spouse/D.P. |
Son |
Dtr |
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D.O.B. |
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Last Name, First Name |
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M/F |
Spouse/D.P. |
Son |
Dtr |
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D.O.B. |
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*Last Name, First Name |
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M/F |
Spouse/D.P. |
Son |
Dtr |
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D.O.B. |
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*Last Name, First Name |
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M/F |
Spouse/D.P. |
Son |
Dtr |
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D.O.B. |
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*There is an additional monthly premium of $10.00 for each family member in excess of five (5). |
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Signature |
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Date |
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Broker Information |
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Broker Name |
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SSN/Tax ID # |
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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 |
www.healthplex.com |
P |
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Print Date |
"PLEASE PRINT OR TYPE ALL INFORMATION"