• Delta Dental Application

  • Section 1: Instructions

  • 1. This form is for adults and parents/guardians of children wishing to apply for Delta Dental benefits through the HFM/Cascade Dental Plan.

    2. Answer all questions completely. An incomplete application will delay the renewal process.

    3. Review the "checklist" (Section 6) at the end of this application to ensure you have provided all of the required information.

     

    If you have any questions about this application, please call or text Ashley Fritsch at 734-328-9717 or email afritsch@hfmich.org.

  • 1. This form is for adults and parents/guardians of children wishing to renew their Delta Dental benefits through the HFM/Cascade Dental Plan.

    2. Answer all questions completely. An incomplete application will delay the renewal process.

    3. Review the "checklist" (Section 6) at the end of this application to ensure you have provided all of the required information.

     

    If you have any questions about this application, please call or text Ashley Fritsch at 734-328-9717 or email afritsch@hfmich.org.

  • Section 2: Information About Your Bleeding disorder

  • In order to remain enrolled, HFM requires a current Verification of Bleeding Disorder (VBD).  A VBD in letter format by mail, fax, or email, should be from the year 2023 and come from a doctor, hematologist, or Hemophilia Treatment Center (HTC) indicating you have a bleeding disorder.  Please DO NOT INCLUDE ANY MEDICAL RECORDS.

    If you are able to provide a VBD, be sure to complete all portions of this application by December 1, 2023.  

    If you are unable to provide a VBD, you are ineligible to receive benefits for 2024, and your current benefits will terminate on December 31, 2023.

  • Section 3: Applicant Information

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  • Section 4: Enrollment Information

  • Does the applicant have any special dental care circumstances? If yes, please check all that apply.

    Please note that exceptions for special circumstances are extended on a case-by -case basis/yearly renewal in coordination with your (or your child's) HTC Social Worker or Nurse.


  • Section 5 Verifying Your Understanding of this Application

  • 1. I understand that the HFM/Cascade Dental Plan can only accept a limited number of applicants and that priority is given to applicants based on their accss to both resources and dental care. I understand that I (or my child) may be placed on a waiting list if there are not spaces available when my (or my child's) application is received. 

    2. I understand that until HFM approves my (or my child's) application no coverage will be effective. 

    3. I understand that I (or my child) am (is) subject to disenrollment and exclusion from this program if this information is false, fraudulent or contains international misrepresentation of facts.

    4. I understand that it is my responsibility to inform HFM of any changes that may affect my (or my child's) eligibility, including any dental insurance that I (or my child) may obtain in the future.

    5. I understand that if I (or my child) move out of the state of Michigan, I must notify HFM so that I can be dis-enrolled.

    6. I understand that annual re-enrollment is necessary in order that my (or my child's) benefits remain active. I understand that if I do not complete the annual re-enrollment application, my (or my child's) enrollment will be terminated.  

    7. I understand that if I voluntarily dis-enroll myself (or my child) or if I (or my child) am involuntarily dis-enrolled from the HFM/Cascade Dental Plan, I (or my child) may not reapply for at least one year after my (or my child's )coverage ends.

    8. I understand that, by signing below, I certify that all information and documentation provided as part of this application are complete, accurate and true to the best of knowledge and belief. 

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  • Section 6: Checklist for submitting your application

  • Verification of Michigan Residency

     

    Upload one - OR - the other of the options below. 

    If you are unable to upload documents you may email them to Ashley Fritsch at afritsch@hfmich.org. They may also be faxed to 734-544-0095.  PLEASE make sure that the copies you are providing are clear and not dark or blurry as this will delay the application process.

  • Verification of Bleeding Disorder

    A letter from your Hemophilia Treatment Center, treating doctor, or Hematologist verifying the Applicant has been diagnosed with a bleeding disorder is required. Please ask whomever is providing your treatment to send a letter via secure email to afritsch@hfmich.org or fax the VBD to 734-544-0095.  

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  • Parent/Guardian/Personal Representative (if applicable):

  • AUTHORIZATION

    I authorize:  Hemophilia Foundation of Michigan, 1921 W. Michigan Ave., Ypsilanti, MI  48197, 734-544-0015

    TO RELEASE the above-named applicant's protected health information TO AND OBTAIN Information FROM:

     

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  • EXTENT OF AUTHORIZATION:

  • This information may be used by the person I authorize to receive this information to assist in determination of eligibility for the HFM/Cascade Dental Plan, billing or claims payment and management of dental program benefits and coordination of dental care.

    I understand that this consent will remain in effect until I give written notice to discontinue.  I have the right to change my mind and revoke this authorization at any time.  This must be in writing to the Hemophilia Foundation of Michigan.  I also understand that any uses or disclosures already made with my permission cannot be taken back.  I understand that this consent will automatically expire if I am terminated from the Delta Dental program.

    I understand that authorizing the disclosure of this health information is voluntary.  I also understand that I may refuse to sign this authorization and that my refusal to sign will not affect my eligibility for the HFM/Cascade Dental Plan unless the information is necessary to demonstrate that I meet elibility or enrollment criteria.

    By signing this authorization, I understand that any disclosure of information carries with it the potential for an unauthorized re-disclosure and the information may not be protected by federal privacy rules.  I further understand that I may request a copy of this signed authorization.

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  • Section 7: Participant Acknowledgement of Responsibilities Form

  • The Hemophilia Foundation of Michigan and Cascade Hemophilia Consortium are pleased to be able to provide this program to you, and we thank you for your interest.  We want to ensure that you fully understand the coverage provided and the limitations.

    Please click each box after reading to indicate that you understand and agree to your program responsibilities. 

     

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