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Individual Information
Fields noted with an asterisk (*) are required.
Enrollee First Name*    
Enrollee Last Name*    
Enrollee ID*    
New Name (if applicable)    
Enrollee Date of Birth* / / (mm/dd/yyyy)    
Street Address*    
ZIP Code* -    
E-mail Address*    
Phone Number ( ) - Fax Number ( ) -
Please check here if this is a new address.
Requested Action
Please check the appropriate areas below that apply to your request.
Be sure to first provide your name, e-mail address and enrollee ID number above.
Please verify my/my family's eligibility for dental coverage.
I would like a description of my dental benefits (Evidence of Coverage/Disclosure).
I would like a description of my vision benefits (Evidence of Coverage/Disclosure).
I would like an additional Identification Card.
I am requesting a transfer to a different dental office.
I am requesting a transfer to a different vision office.
Office provider number you wish to transfer to: **
** NOTE: The dental/vision office number is located at the top of each record in the printed and online directories. The transfer will be effective on the first of the following month if the request is received by the 21st of the month. Treatment in progress must be completed by the attending dental/vision provider before a transfer to a new office is approved. Dental example: If you are in the process of receiving a crown, the tooth has been prepared for the procedure, impressions have been made and crown has not been placed.
Other question or request.
Please state your question clearly and fully. Do not use this to file a complaint. See top of this form for more information.

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If you prefer to mail or telephone your inquiry, you can reach us at:

DeltaCare USA/DeltaVision Customer Service
P.O. Box 1803
Alpharetta, GA 30023
(800) 422-4234

(562) 809-7059

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