The Dental Program Administrative Guide was designed to assist campuses with
the administration of CSU Dental Benefits. All necessary forms and contacts have been
provided.
General Instructions
General instructions and information pertaining to the administration of dental benefits for the CSU.
Appendix A
This section contains the necessary enrollment forms.
Dental Plan Enrollment Authorization
Declaration of Domestic Partnership
Statement of Financial Liability for Domestic Partner
Domestic Partner Tax Dependent Certification Form
Domestic Partner Tax Dependent Cancellation Form
Affidavit of Eligibility for Economically Dependent Children
Appendix B
Instructions for completing the Dental Plan Enrollment Authorization Form (STD-692)
Appendix C
Dental Plan Permitting Event Charts
Appendix D
Request for continued Dental Plan coverage and Direct Payment Authorization, or Termination of Enrollment Form
Appendix E
Continuation of coverage information and documents.
 Group & Sublocation Numbers
Delta Dental Plan: COBRA Notice, COBRA Form
PMI DeltaCare Dental Plan: COBRA Notice, COBRA Form
Appendix F
List of employee groups eligible for Enhanced Dental Coverage
Appendix G
CSU Benefits Officers
Appendix H
Directory of Dental Plan Contacts
Appendix I
Lecturer Benefits Revised Eligibility
Appendix J
Additions and Deletions Sheet for Administrators, Delta Dental Plan
|
