EMPLOYER GROUP APPLICATION Small Group: 2 - 9 Employer Paid / Non-Voluntary ACH Form, Web & E-billing Authorization Form, and HIPAA Certification must be included with the Employer Group For Delta Dental internal use only Application in order for this application to be considered Group # complete. A copy of the Unemployment Insurance Report of Worker Wages must also be submitted. Incomplete Subgroup # applications may be returned. Please fill out/select from all yellow and green fields as applicable. Blue areas are reserved for Delta Dental. Contact Information Legal Group Name: Street Address: City, State, Zip: Phone: FAX: E-mail: Salutation Click on field to select from list Contact Title: Name: Phone: FAX: E-mail: If Billing is different from above, please complete below : Is this a TPA? Select Yes or No to indicate if this is a Third Party Administrator Billing Entity Name: Billing Address: City, State, Zip: Contact Title: Name: Phone: FAX: E-mail: Eligibility and Enrollment Select Product: Click on field to select from list Note: EyeMed Vision Discount Plan included with all products PARTICIPATION: Total Number of Enrolled Employees Enter number Total Number of Eligible Employees Enter number NOTE: All full time employees are eligible. EMPLOYER CONTRIBUTION: Employee % Enter percent Dependent % Enter percent EMPLOYEE ELIGIBILITY AND COVERAGE: Unless otherwise indicated, all employees become eligible FOM following 3 months of hire, Dependent Eligibility: Children to age 25 EOM, regardless of student status. Delta Dental Group App - SmGrp 2-9 Revised 5/7/2009 page 1 If all employees become eligible the first of the month (FOM) following 3 months of hire, select "Yes": Click on field to select Yes or No If "No", to match medical eligibility, please select one of the Click on field to select from list; leave blank if following: above selection is "Yes" Minimum number of hours worked per week to establish eligibility: Enter number of hours Does your company cover same sex Domestic Partners? Click on field to select from list GENERAL INFORMATION Enter name of previous dental carrier: Enter name If internal transfer group from Delta Dental, enter prior Delta Dental group If applicable, enter prior group number number: NAICS (Industry Code) Enter number - must be completed by Broker or Employer ENROLLMENT METHOD, RATES AND BILLING Tier Structure # 4 Payment Method: ACH RATES $ Employee Only Initial Enrollment Method: Paper $ Employee + Spouse $ Employee + Children Ongoing Enrollment Web Tool* $ Employee + Family Method: * Web (Employer Connection) enrollment requires additional forms for security purposes Enrollment Type: Late Enrollment Enrollment must be made within 31 days of becoming eligible or within 31 days of loss of coverage through another group dental plan. Persons who do not enroll when initially eligible must be enrolled for 12 months before receiving benefits for services other than diagnostic & preventive. 100% employer contribution for all eligible employees, and 100% of eligible employees must enroll. Contract Information and Signatures Group Effective Date Enter date (mm/dd/yyyy) Benefit Period for deductibles and maximums: Calendar Year Contract Period (number of months) 24 months The first month's premium is estimated to be: $ Delta Dental Group App - SmGrp 2-9 Revised 5/7/2009 page 2 It is agreed that the Group Contract will not become effective unless and until this application is approved and accepted by DeltaDental of Colorado. It is understood that this application will be considered part of the Contract between Delta Dental of Colorado and the Group. Account Executive Bruce Grider Account Manager Sherl Stills Authorized Signature for group Delta Dental of Colorado Signature Date Date It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies. Producer Information Producer Name: Producer Firm: Street Address: City, State, Zip: Phone: FAX: E-mail: Do you currently receive commissions from Delta Dental? Select Yes or No If no, please complete and return Agent Agreement TIN# Enter number E-commissions? Select Yes or No Please send completed and signed Master Application including ACH Form, Web & E-billing Authorization Form, HIPAA Form, Employee Enrollment Forms, Prior Carrier bill if applicable, Tax and Wage Report and estimated first month's premium payment to: Delta Dental of Colorado Sales and Marketing - Small Group Business Unit 4582 South Ulster Street Ste 800 Denver, CO 80237 Delta Dental Group App - SmGrp 2-9 Revised 5/7/2009 page 3 Automatic Draft Authorization (ACH) Please print or type when completing this form. Purpose of Authorization (please indicate one) New Authorization Changes to Existing Authorization (Note: Changes will be completed within 30 days of receipt date) Name of Company Group Number Address City, State, Zip Contact Name Phone Number Fax No E-mail Address Name of Depositor Preferred to the to Receive Summary Invoice In additionMethodsummary invoice, do you wish FAX E-mail to receive a complete eligibility list each month? YES NO For Self-funded Groups Only The automatic draft applies to: Administrative Fees Only Claims Payment Only Administrative Fees & Claims Payment I (We) hereby authorize DELTA DENTAL OF COLORADO hereinafter called “COMPANY”, Type of Account: Checking Savings Name of Financial Institution Branch Transit/ABA No Account No This authority is to remain in full force and effect until COMPANY has received notification Authorized on behalf of Printed Name Signature Date Fax this form to (303) 221-4457, ATTN: Accounts Receivable ACH Rev Mar 2007 pkz Delta Dental of Colorado Group Health Plan Certification The Group Health Plan (Plan) does hereby certify to the following: 1 That the Plan is a “group health plan” within the meaning of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). That the Plan documents you distribute to employees informing them about their benefits or the Plan documents 2 you are legally required to maintain for your employee benefits plans (such as ERISA Plan documents) have been amended, as required by 45 CFR §164.504(f) and §164.314(b) HIPAA, to incorporate the following provisions and you, as the Plan Sponsor (employer) agreed to: Not use or further disclose health information protected under HIPAA (Protected Health Information (PHI)) other 2a. than as permitted or as required by law; Ensure that any agents, including subcontractors, to whom you provide PHI agree to the same restrictions and 2b. conditions that apply to you with respect to such information; 2c. Not use or disclose PHI for employment-related actions and decisions; Report to Plan’s designee any PHI use or disclosure that you become aware of that is inconsistent with the uses or 2d. disclosures provided for; 2e. Make PHI available to an individual based on HIPAA’s access requirements; Make PHI available for amendment and incorporate any PHI amendments based on HIPAA’s amendment 2f. requirements; 2g. Make available the information required to provide an accounting of disclosures; Make internal practices, books and records relating to the use and disclosure of PHI received from the Plan 2h. available to the Secretary of Health and Human Services to determine the Plan’s compliance with HIPAA; Ensure that adequate separation required by HIPAA 45 CFR §164.504(f)(2)(iii) is supported by reasonable and 2i. appropriate security measures; If feasible, return or destroy all PHI received from the Plan that you, as the Plan Sponsor, still maintain in any form 2j. and retain no copies of such PHI when no longer needed for the specified disclosure purpose. If return or destruction is not feasible, you will limit further uses and disclosures to those purposes that make the return or destruction infeasible; Implement administrative, physical, and technical safeguards that reasonably and appropriately protect the 2k. confidentiality, integrity, and availability of the electronic protected health information that it creates, receives, maintains, or transmits on behalf of the group health plan; 2l. Ensure that any agent, including a subcontractor, to whom it provides this information agrees to implement reasonable and appropriate security measures to protect the information; and 2m. Report to the group health plan any security incident of which it becomes aware. 3 The undersigned further certifies that he or she has the authority to sign on behalf of the Plan. Printed Name of Plan Representative Delta Dental Group Number Signature of Plan Representative Date Delta Dental of Colorado puts a high priority on compliance with laws and regulations under which it operates and is dedicated to protecting the information of our enrollees. Group Number: Website & E-Billing Authorization Form Small Groups (under 100) Purpose: This form allows a Plan Sponsor to: (1) open Website Accounts for authorized individuals and business associates for purposes of submitting enrollment information and obtaining access to bills; and (2) request that Delta Dental of Colorado (DDCO) send bills via e- mail. Please complete all fields that are shaded in yellow. Plan Sponsor Requesting Authorization Group Name: Group Number: Address: E-mail Address: Telephone: Complete one form for each employee requiring access. Provide user name, e-mail, and phone number for the individual and identify the access authorized for that individual by checking the box next to the service. Please also supply a key word in the event a password is forgotten (applicable only for those requiring a password). Check the appropriate box below Add User Terminate User E-mail: User Name: Phone Number: Key Word (choose one): Last 4 digits of SSN: Pet Name: Mother's Maiden Name: The group, acting through its undersigned representative, certifies that the individual identified above is authorized to access the checked websites below and perform the functions associated with each website on the group’s behalf and hearby authorizes DDCO to open a website account for the individual set forth above (access requires password). Check the appropriate box(es) below to indicate approved access: Receive bills via e-mail View Only - bills Submit, modify and view enrollment data View Only - enrollment data (cannot make changes or updates) AUTHORIZATION AND CONDITIONS FOR PRIVILEGES GRANTED In consideration for the privileges set forth in this Website Account and E-Billing Authorization form, the group, acting through its Group Administrator hereby agrees to the following conditions: 1. DDCO may rely on electronically submitted enrollment data to the same extent as if submitted by non-electronic means; 2. Group will undertake reasonable measures to safeguard account information, including user name and password, and to prevent unauthorized access to the website by someone acting or purporting to act on the group’s behalf; 3. All requests to close the Website Account, or stop the receipt of bills via e-mail must be submitted via e-mail to firstname.lastname@example.org, or faxed to 303.741.4233. DDCO shall have three business days (excluding holidays) to process such requests; 4. Group shall be solely responsible for any liability arising from the use of the Website Account or receipt of bill via e-mail and shall indemnify, hold harmless and defend DDCO against any claim arising from the Authorized User’s use of the Website Account, practice of sending bills via e-mail or the groups failure to safeguard account information, including, but not limited to, errors and omissions and violations of state and federal privacy laws; and 5. The individual signing this application form has the authority to permit the requested access and bind the group to the terms and conditions set forth above. Group Adminstrator: Date: 05-2009 Delta Dental Group Implementation Check List Delta Dental makes every effort to have a smooth and efficient new group setup. Our processes serve to provide the member with timely eligibility so they th have no delays in seeking the dental care they need. Please submit new cases with correct and completed documentation by the 25 of the preceding month. Completed the Master Application (please include the forms located in the tabs at the bottom of the Master Application document) Enrollment Forms Employer Connection Authorization form (required for 2-9 plans and all groups wanting to provide eligibility via the website) Automated Clearing House Authorization form (required for 2-9 plans) HIPPA Form Copy of Prior Carrier Bill (if applicable to takeover credits) Copy of Tax and Wage Report or Schedule C (for 2-9 plan options only) Estimated 1st month premium (group implementation will be delayed if not received with the above listed documentation) Mail completed forms to: Delta Dental of Colorado Attn: Small Group Sales 4582 S. Ulster Street, Suite # 800 Denver, CO 80237 Small Groups with 2-9 enrolled employees can print ID Cards at www.deltadentalco.com. The member must register first and then will be able to print the card. Employers who have access to the secured area of the website will also be able to print ID Cards. Group Premium Calculation (Optional) To calculate the estimated first month premium for your group: 1. Fill in the rates for plan chosen on the table below. 2. Multiply rates by the number of employees in each membership category to determine total monthly premium. This amount is due with your application Number Rate Monthly Employees Premium Employee Only x = Employee/Spouse x = Employee/Child(ren) x = Employee/Family x = No Coverage/ coverage elsewhere x = Total Amount Due Please submit all documents and estimated 1st month premium payment by the 25th of the preceding month.
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