DentaSelect (PPO) Forms

New Sale Forms

• Check List
  1. Small Group (2-9 employees - EFT mandatory)
  2. Large Group (10+)
• Group Application for Master Group Contract (Small & Large group)
• Verification of Eligibility (VOE)
• Electronic Funds Transfer (EFT mandatory for all small groups between 2-9)
• Online Enrollment / Billing Form
• Employee Enrollment Form - DentaSelect

Optional Forms

• Dentist Recruitment
• Change Request Form (DentaSelect)
• Privacy Notice (DCP)

** If you are not sure which forms to use please contact your Sales Representative at 513-554-1100 or 800-367-9466 for more information.

** Incorrect Forms will not be accepted

New Sale Forms

• Check List
• Group Application for Master Group Contract (MNL)
• Verification of Eligibility (VOE)
• Employee Enrollment Form - DentaSelect (MNL)

Optional Forms

• Dentist Recruitment
• Change Request Form (DentaSelect)
• Privacy Notice (MNL)

** If you are not sure which forms to use please contact your Sales Representative at 513-554-1100 or 800-367-9466 for more information.

** Incorrect Forms will not be accepted