Forms / Disclosures
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.
Claim Forms
English Dental Claim Form
Spanish Dental Claim Form
Ameritas Vision or LASIK Claim Form – for Vision Perfect plans, Dental plans with LASIK, Fusion plans and Dental plans with Exam Only benefit
Ameritas Rewards Vision Reimbursement Form
Spanish Ameritas Vision Claim Form
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
Claim Forms (NY)
English Dental Claim Form (NY)
Spanish Dental Claim Form (NY)
Ameritas of New York Vision or LASIK Claim Form (NY) – 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)
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
Enrollment Forms
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
Enrollment Forms (NY)
Dental/Vision (NY)
Dental/Vision High/Low (NY)
Dental Only (NY)
Vision Only (NY)
Spanish Dental/Vision (NY)
Spanish Dental/Vision High/Low (NY)
State-Specific Enrollment Forms
Dental/Vision – Illinois
Dental Only – Illinois
Vision Only – Illinois
Dental Only – Minnesota
Vision Only – Minnesota
Dental/Vision – Minnesota
Dental/Vision High/Low – Minnesota
Dental Only – Montana
Vision Only – Montana
Dental/Vision – Montana
Dental/Vision – New Mexico
Dental/Vision High/Low – New Mexico
Dental Only – New Mexico
Vision Only – New Mexico
Dental/Vision – Utah
Dental Only – Utah
Vision Only – Utah
Dental/Vision – Virginia
Dental Only – Virginia
Vision Only – Virginia
Dental/Vision – Washington
Dental Only – Washington
Vision Only – Washington
Dental/Vision High/Low – Washington
Vision High/Low – Washington
*Please contact your Ameritas sales rep for enrollment forms in Massachusetts.
Group Application Forms
Please use the preliminary group application to apply for insurance for a new group with Ameritas. Provide the appropriate language services document along with the Employer Group Application if a Health Care Reform (ACA) plan has been selected.
Dental/Vision – all states except Colorado, Maryland, New Jersey, New Mexico, New York and Washington
State-Specific Group Application Forms
Please use the preliminary group application to apply for insurance for a new group with Ameritas. Provide the appropriate language services document along with the Employer Group Application if a Health Care Reform (ACA) plan has been selected.
Dental/Vision – Colorado
Dental/Vision – Maryland
Dental/Vision – New Jersey
Dental/Vision – New Mexico
Dental/Vision – New York
Dental/Vision – Washington
Census Enrollment
Please use the attached census format for the enrollment of a new group when submitting the new case.
State-Specific ADA Claim Forms
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
Iowa Non-Covered Services Decision
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.
Washington - Contracted Health Care Benefit Managers
| Company | Functions Provided |
| DenteMax, LLC | Leases dental network to Ameritas, Provider credentialing |
| Government Employees Health Association (GEHA) Connections Dental Network | Leases dental network to Ameritas, Provider credentialing |
| EyeMed, LLC | Leases vision network to Ameritas, Provider credentialing |
| P&R Dental Strategies, LLC | Utilization review of dental claims |
| Zelis | Leases dental network to Ameritas, Provider credentialing |
New Jersey Application to Appeal a Claims Determination
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
New York Confidentiality for Victims of Domestic Violence and Endangered Individuals
Your safety is important to us. Find information about your rights regarding domestic violence privacy and confidentiality.
NY Domestic and Sexual Violence Information
Dependent Status Forms
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
English Request for Dependent Child Exception(NY)
Spanish Request for Dependent Child Exception
Spanish Request for Dependent Child Exception(NY)
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
Maternity Dental Benefit Disclosure Form
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
Medically Necessary Orthodontia 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)