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When accessing or downloading online forms, you agree to release, indemnify and hold harmless Ameritas Life Insurance Corp. and/or its subsidiaries for any damage or liability encountered from using these forms. Please remember to keep only the most current Ameritas or Ameritas Life Insurance Corp. of New York forms on file.

English Dental Claim Form (fillable PDF)
Spanish Dental Claim Form
Ameritas Vision Claim Form (fillable PDF) - for Vision Perfect plans, Dental plans with LASIK, Fusion plans and Dental plans with Exam Only benefit
Ameritas Rewards Vision Reimbursement Form (fillable PDF)
Spanish Ameritas Vision Claim Form  (fillable PDF)
EyeMed Vision Out-of-Network Claim Form
VSP Vision Out-of-Network Claim Form
Total Vision Accidental Loss of Sight Claim Form
SoundCare Claim Form - for hearing care plans
Individual Dental Claim Form - for individual plans
Individual Vision Claim Form - for individual plans (fillable PDF)

English Dental Claim Form (NY) (fillable PDF)
Spanish Dental Claim Form (NY)
Ameritas of New York Vision Claim Form (NY) (fillable PDF) - for Vision Perfect plans, Dental plans with LASIK, Fusion plans and Dental plans with Exam Only benefit
Spanish Ameritas of New York Vision Claim Form (NY) (fillable PDF)
EyeMed Vision Out-of-Network Claim Form (NY)
VSP Vision Out-of-Network Claim Form (NY)
Total Vision Accidental Loss of Sight Claim Form (NY)
SoundCare Claim Form (NY) - for hearing care plans

Use our enrollment forms to enroll, change your name, add/drop dependents or waive coverage.

Choose from Dental/Vision, Dental Only or Vision Only. If your plan is High/Low or Triple Option, choose one of those forms and be sure to select which option you want. We also have Spanish versions of our two most popular Dental/Vision forms. *All enrollment forms are fillable.

Dental/Vision 
Dental/Vision High/Low 
Dental/Vision Triple Option 
Dental Only 
Dental Only High/Low 
Dental Only Triple Option 
Vision Only 
Vision Only High/Low 
Vision Only Triple Option 
Spanish Dental/Vision 
Spanish Dental/Vision High/Low

Some states require you to use the ADA Claim Form for paper submission of dental claims. If you have services performed in one of the following states, you must use the ADA form: GA, ID, IL, IN, KY, LA, MD, MN, MO, MT, NC, ND, NJ, NV, NY, OH, OK, SD, TN, TX, VT, WI, WY. This listing of states is subject to change due to state regulations.
ADA Dental Claim Form

The Iowa Supreme Court has determined that Iowa law does not allow dental insurers to set maximum fees on services that the insurer does not cover or reimburse. As your insurer or administrator, we will have no involvement in setting the fee for such services, and any questions or concerns you may have about such fees should be directed to your dentist.

You have the right to appeal our claims determination(s) or appeal an apparent lack of activity on a claim you submitted.
New Jersey Application to Appeal a Claims Determination

Your safety is important to us. Find information about your rights regarding domestic violence privacy and confidentiality.
Domestic and Sexual Violence Information

Exception to Dependent Child Definition

If you have non-traditional dependents under your care, submit the form below to determine if they qualify for dependent status.
English Request for Dependent Child Exception 
Spanish Request for Dependent Child Exception

Enroll Dependent Under Disabled Status

If your child is over the dependent age (as specified in your plan) and is considered fully disabled, have your child's physician complete this form.
English Statement of Health
Spanish Statement of Health

If you or your dependent is pregnant and your policy includes the maternity dental benefit, complete this form.
English Maternity Disclosure Form
Spanish Maternity Disclosure Form

If the policy has coverage for medically necessary orthodontia, please have your provider complete and submit this form.
HLD Index Score Sheet for Medically Necessary Orthodontics
Salzmann Index Evaluation Detailed Instructions for Completion (Indiana Only)

To become appointed with Ameritas or Ameritas Life Insurance Corp. of New York and be compliant with HIPAA Privacy regulations, simply fill out our combined appointment application and business associate addendum. Included with the appointment application is the Direct Deposit Authorization Form, so you can have your commissions deposited directly into your bank account. Mail or fax a completed copy of the form and a copy of your license to the Group Sales Office nearest you.

Appointment Application/Business Associate Addendum

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