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Dental Prime and Dental Complete Broker Services
Group post-sale questions? Call Employer Services at (877) 567-1799.
Individual pre-sale questions? Call (877) 567-1807, Mon-Fri 8am – 8pm EST.
Individual dental post-sale questions? Call (877) 604-2158, Mon-Fri 8am – 8pm EST.
Individual vision post-sale questions? Call (866) 723-0515
Individual billing questions? Call (855) 881-7217
Individual commission payment questions? Call (877) 606-3409 or email firstname.lastname@example.org
These forms apply to group only, unless noted with an *, which indicates form applies to group and individual coverage.
Dental Prime and Dental Complete Tools
Broker Rate Calculator
Broker Rate Calculator – Password Request Form
Online Commission Reports Tool*
Online Commission Reports User Request Form*
ACH Commission Form*
Agent of Record Assignment
Plan Designs (Groups 2-50)
Plan Designs (Groups 51+)
Group Implementation & Enrollment
Group Master Application (for groups 2 - 50)
Submission Requirement Checklist (for groups 2 - 50)
Census Enrollment Spreadsheet
Member & Group Forms
Membership Enrollment Form
Membership Enrollment Form – Spanish
Membership Maintenance Form
Authorization to Release Information*
Authorization to Release Information - Spanish*
HIPAA Designated Contact Form
Disabled Dependent/Michelle’s Law Application*
Claims & Additional Benefits Forms
Dental Claim Form*
International Emergency Dental Program Flyer*
International Emergency Dental Program Frequently Asked Questions*
Extra cleaning sign up form for diabetic and pregnant members*
Online Capabilities Flier
Online Enrollment Billing Reports Request Form
Dental Employer Online Services Demo
Group Billing Forms
Weekly ASO Billing Schedule
Monthly Fully Insured Billing Schedule
© 2013 BlueCross BlueShield of Georgia
Blue Cross and Blue Shield of Georgia, Inc. and Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. are independent licensees of the Blue Cross and Blue Shield Association. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.