Are you considering enrolling in a health plan? Choosing the right plan for your needs can be a stressful and tedious process. To make this process easier, Healthplex has created an online enrollment form that simplifies the paperwork involved with selecting coverage. This post will provide an overview of the Healthplex Enrollment Form and its requirements so that you have all of the information necessary to make an informed decision about which plan works best for you.
| Question | Answer |
|---|---|
| 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 |
|
|
|
|
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 |
www.healthplex.com |
P |
|
Print Date |
"PLEASE PRINT OR TYPE ALL INFORMATION"