Dental Enrollment Form - Forms

Yes, I would like to enroll in the Optional Comprehensive Dental Plan.(Required)

This is an optional dental coverage which is in addition to your Medicare Part B and CCHP plan premium.

Applicant Information

Name(Required)

First Middle Last

CCHP Member ID#(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Gender

Date of Birth (mm/dd/yyyy)(Required)

Home Phone

Work Phone

Note to Applicant: I will be auto-assigned to a Contract Dentist by Delta Dental. I can change contract dentist by contacting Delta Dental Customer Service at 1-855-245-1120, 8am - 8pm. 7 days a week October 1st through March 31st; Monday through Friday from 8am-8pm (TTY: 711) after I receive member ID card from Delta Dental.

Chinese Community Health Plan (CCHP) is a Medicare Advantage HMO plan with a Medicare contract and a California Medicaid Program contract for our SNP. Enrollment in CCHP depends on contract renewal.

The CCHP Senior Program (HMO) Optional Comprehensive Dental Plan is only available to individuals enrolled in or applying for coverage in CCHP Senior Program (HMO).

The CCHP Senior Value Program (HMO) Optional Comprehensive Dental Plan is only available to individuals enrolled in or applying for coverage in CCHP Senior Value Program (HMO).

I acknowledge that I must pay an additional premium if I enroll in the Optional Dental Coverage provided by Delta Dental of California. This premium is paid to CCHP. I must continue to pay my Medicare Part B premium. I will receive a monthly bill, which is separate from my monthly plan premium. This program is voluntary. All dental care must be received within the DeltaCare, USA network. I may choose to drop coverage at any time. If I choose to drop the program, I may not reenter the program until the next Annual Election Period. I understand that the dental coverage is provided by Delta Dental of California as described in the Evidence of Coverage.

I understand that a Contract Dentist will be auto-assigned by Delta Dental, I can change contract dentist by contacting Delta Dental Customer Service at 1-855-245-1120, 8 a.m. – 8 p.m. 7 days week October 1st through March 31st; Monday through Friday from 8 a.m. – 8p.m. (TTY: 711) after I received my member ID card.

I understand that my signature (or the signature of the person authorized to act on my behalf under the laws of the State where I live) on this application means that I have read and understand the contents of this application. If signed by an authorized individual (as described above), this signature certifies that 1) this person is authorized under State law to complete this enrollment and 2) documentation of this authority is available upon request by CCHP or by Medicare.

Signature

Today's Date

If you are the authorized representative, you must sign above and complete the following information:

Name

First Last

Address

Phone Number

Relationship to Enrollee

Chinese Community Health Plan (CCHP) is a Medicare Advantage HMO plan with a Medicare contract and a California Medicaid program contract for our HMO D-SNP. Enrollment in CCHP depends on contract renewal. CCHP complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.
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