Northeast Delta Dental

Forms for Our Employers and Groups

Find the helpful forms and materials to assist you with administering Northeast Delta Dental benefit products and services.

Business Forms

• COBRA Election Form 
• DeltaVision Termination Report
• Dependent Verification Request
• Employee Enrollment / Change Form - State of ME (Dental) 
• Employee Enrollment / Change Form - State of NH (Dental) 
• Employee Enrollment / Change Form - State of VT (Dental) 
• Employee Enrollment / Change Form - State of ME (Vision) 
• Employee Enrollment / Change Form - State of NH (Vision) 
• Employee Enrollment / Change Form - Dual Option - State of ME, NH & VT
• Employee Enrollment / NH & VT Continuation of Coverage
• GOSE Refund Request Form
• Group Supplies Order Form
• Payment Option Form 
• Termination Report Form

Informational Materials

• Just a Click Away Flier
• Open Enrollment Poster 

Compliance

• HIPAA Business Associate Agreement
• HIPAA Individual Authorization Form
• HIPAA Privacy Notice

Get the Adobe PDF Viewer.

Requires Microsoft Word^TM or OpenOffice.