Massachusetts State Health Care Professionals’ Dental Fund

DENTAL/VISION ENROLLMENT/CHANGE FORM
COMPLETE ALL SECTIONS BELOW OR DOWNLOAD PRINTABLE VERSION

Reason for submission (Check all that apply) *

Please select the plan you wish to enroll (Check one box only) *

Add More Dependent(s)

YOU MUST INCLUDE COPIES OF DOCUMENTATION THAT SUPPORT YOUR DEPENDENT RELATIONSHIP (I.E. - MARRIAGE, BIRTH, ADOPTION, ETC.) AS WELL AS A PHYSICIAN STATEMENT FOR CHILDREN LISTED AS MENTALLY OR PHYSICALLY HANDICAPPED. FAILURE TO PROVIDE COMPLETE SUPPORTING DOCUMENTATION CAN RESULT IN A DELAY OF ELIGIBILITY.

The Fund and the Employee agree that this form may be electronically signed and that the electronic signature appearing on this form is the same as handwritten signatures for purposes of validity, enforceability and admissibility.


EMPLOYER PAYROLL DEDUCTION AUTHORIZATION OR AUTHORIZATION TO DISCONTINUE DEDUCTION SECTION

I , Employee No. authorize my employer to deduct the amount noted below from my wages and to transmit the deduction amount to the Massachusetts State Health Care Professionals' Dental Fund in order to pay for HIGH Option dental benefits for me and/or my dependent(s). These deductions are in addition to the Employer's contribution to the Fund on my behalf. This authorization shall be in effect for no less than one (1) year, unless you have a family status change.


CHECK THE APPLICABLE BOX FOR THE EMPLOYER WHERE YOU WORK:

ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES A STATEMENT CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT WHICH IS A CRIME.