Delta Dental Application

Select application type:*

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.

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.

Has the applicant been diagnosed with a bleeding disorder?*

YesNo

Does the applicant receive medical care at a Hemophilia Treatment Center?*

YesNo

If yes, at which HTC do they receive treatment?

If no, what is the name of the applicant's hematologist?

Social Security (no dashes or spaces)*

Date of Birth*

Date

Full Name*

First NameLast Name

Preferred Name

E-mail*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number*

Area CodePhone Number

Can we leave a message at this number?*

YesNo

Is the applicant a resident of the state of Michigan?*

YesNo

Is the applicant eligible for dental insurance through an employer or parent/guardian employer?*

YesNo

If eligible for employer sponsored dental insurance, please share why applicant is not covered under that plan.

Does the applicant have coverage under Children's Special Health Care Services?*

YesNo

Does the applicant have coverage under Medicaid?*

YesNo

Does the applicant have coverage under Medicare?*

YesNo

If yes, is it a Medicare Advantage Plan?*

YesNoDoes not apply

Does the Medicare Advantage Plan have dental coverage?*

YesNoDoes not apply

Is the applicant covered under any other dental plan?*

YesNo

If yes, what plan is the applicant covered under?

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.

*

Access issueExtensive dental work in the coming yearYou have Medicaid coverage but your dental work will be in excess of your benefitsDoes not applyOther

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.

Signature*

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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.

Upload a copy of Michigan Driver's License or MI State ID Card OR

Upload a copy a recent bill that is in your name showing your name and current address.

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.

Applicant Name*

First NameLast Name

Applicant Date of Birth*

Date

Parent/Guardian/Personal Representative (if applicable):

Name

First NameLast Name

Relationship to applicant:

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:

Hemophilia Treatment Center and/or Hematologist*

Health Care provider address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Health Care provider phone number*

Area CodePhone Number

EXTENT OF AUTHORIZATION:

Click both boxes after reading and agreeing to them:*

I authorize the release of the above named applicant's information related to the HFM/Cascade Dental Plan application including eligibility for the program, status of the application, dental benefit coverage, dental care needs, and diagnosis and treatment of the above named applicant's bleeding disorder.I understand that this release of information form does NOT include records relating to mental health care, communicable diseases (including HIV and AIDS) or alcohol/drug abuse treatment.

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.

Signature of applicant if over 18 or Parent/Guardian/Personal Representative if applicant is under the age of 18.*

Clear

Today's date:*

Date

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.

1.*

I understand that I must complete all necessary initial enrollment application and forms, including annual renewal forms in order to participate in the program.

2.*

I understand that I (or my child) must attend at least two preventative dental visits each year to utilize this program.

3.*

I agree to call Delta Dental or utilize the Delta Dental Consumer Toolkit that is available on the internet to verify my (or my child's) annual benefits.

4.*

I understand that I am responsible to insure that my (or my child's) dentist is a covered IN NETWORK provider and to request a PRE-TREATMENT ESTIMATE so that I will understand what procedures are covered and what cost I would be responsible for BEFORE I (or my child) receive treatment.

5.*

I understand that I (or my child) have a maximum ANNUAL benefit limit of $1,000 of coverage and that I am responsible for any costs for services above that amount.

6.*

I understand that only certain services are covered and that not all providers are IN-NETWORK. I will be responsible for any costs not covered including if I (or my child) receive services from an Out-of-Network provider.

7.*

I understand that if I dis-enroll myself (or my child) from the program, or my (or my child's) coverage is terminated, I will need to cover any costs for services beyond the covered period of enrollment AND wait one year to re-enroll.

My signature indicates that I agree to ALL of the above listed information and all terms and conditions for this program and that all information that provided in this application is accurate.*

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Delta Dental Application

Section 1: Instructions

Section 2: Information About Your Bleeding disorder

Section 3: Applicant Information

Section 4: Enrollment Information

Section 5 Verifying Your Understanding of this Application

Section 6: Checklist for submitting your application

Section 7: Participant Acknowledgement of Responsibilities Form