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 (NY)
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

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.

Census Enrollment Template 

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

NY Confidential Communication Request Form

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)