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Retiree Self Dental Program ENROLLMENT FORM Los Angeles Plan130 South Alvarado Street, 2nd Floor Los Angeles, CA 90057 (213) 4848480 www.uhh.orgYou must enroll yourself and your covered dependents

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How to fill out retiree self-pay dental program

01

Step 1: Obtain the retiree self-pay dental program application from the appropriate source.

02

Step 2: Fill in the required personal information such as name, address, and contact details.

03

Step 3: Provide your retiree identification number and any other relevant identification information.

04

Step 4: Select the dental plan option that best suits your needs and budget.

05

Step 5: Review the terms and conditions of the program carefully and ensure you understand the coverage and payment details.

06

Step 6: Sign and date the application form.

07

Step 7: Submit the completed application form along with any required payment or documents as specified by the program provider.

08

Step 8: Await confirmation of your enrollment in the retiree self-pay dental program.

09

Step 9: Once enrolled, follow the instructions provided by the program for accessing dental services and making payments, if applicable.

10

Step 10: Keep track of your dental expenses and retain any receipts or documentation for future reference or reimbursement, if applicable.

Who needs retiree self-pay dental program?

01

Retirees who do not have access to dental insurance through their former employer or any other source.

02

Retirees who want to maintain their dental health and receive necessary dental treatments.

03

Retirees who are willing to pay for dental coverage out of their own pocket.

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What is retiree self-pay dental program?

The retiree self-pay dental program is a dental benefits plan that allows retired individuals to continue their dental coverage by paying the premiums themselves, ensuring access to dental services after retirement.

Who is required to file retiree self-pay dental program?

Retired employees who wish to maintain their dental benefits after leaving their employment are required to file for the retiree self-pay dental program.

How to fill out retiree self-pay dental program?

To fill out the retiree self-pay dental program, retirees must complete the designated application form, providing necessary personal and coverage information, and submit it along with payment for the premium.

What is the purpose of retiree self-pay dental program?

The purpose of the retiree self-pay dental program is to provide ongoing dental insurance coverage for retirees, enabling them to receive necessary dental care without interruption.

What information must be reported on retiree self-pay dental program?

The information that must be reported on the retiree self-pay dental program includes the retiree's personal details, previous employment information, chosen coverage options, and payment details.

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