Forms for Our Employers and Groups

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

Authorization Letters

• Group Authorization - Insured 
• Group Authorization - Self-Insured 

Business Forms

• DeltaVision Termination Report
• Dependent Verification Request
• Employee Enrollment / Change Form - (Dental) 
• Employee Enrollment / Change Form - (Vision) 
• GOSE Refund Request Form
• Group Supplies Order Form
• Payment Option Form 
• Termination Report Form – ME & NH  
• Termination Report Form – VT  

Informational Materials

• Benefit Lookup Flyer
• Benefit Lookup Flyer (Spanish) 
• Open Enrollment Poster 

Compliance

• Individual Release of PHI Authorization 
• HIPAA Privacy Notice

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