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 or LASIK 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 or LASIK 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 Triple Option
Dental Only High/Low
Dental Only Triple Option
Vision Only High/Low
Vision Only Triple Option
Spanish Dental/Vision High/Low
Dental/Vision - Illinois
Dental Only - Illinois
Vision Only - Illinois
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
*All enrollment forms are fillable.
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.
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)
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
Ameritas Group Dental, Vision and Hearing Care Protected Health Information Privacy Policies are summarized in our HIPAA Privacy Notice. Please review our Notice of Protected Health Information Practices.
HIPAA Privacy Notice
HIPAA Privacy Notice (Spanish)
GLB Privacy Notice (Gramm-Leach-Bliley)
GLB Privacy Notice (Gramm-Leach-Bliley) (Spanish)
Member Rights and Responsibilities
Authorization for Release of Protected Health Information
Authorization for Release of Protected Health Information (Spanish)
HIPAA Individual Rights Forms
Request for Alternate Means of Communication
Request for Amendment of Protected Health Information
Request for Accounting of Disclosures of Protected Health Information
Request to Inspect or Copy Protected Health Information
Request to Restrict/Terminate Restrictions on Disclosures