When accessing or downloading online forms, you agree to release, indemnify and hold harmless Ameritas Life Insurance Corp. and/or its subsidiaries for any damage or liability encountered from using these forms. Please remember to keep only the most current Ameritas forms on file.
Privacy Forms
Authorization for Release of Protected Health Information
To be in compliance with the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule, a patient/guardian/personal representative must complete this form to authorize disclosure of confidential health information about any insured member. Please print and complete the form and return it to us at:
Privacy Office
PO Box 81889
Lincoln, NE 68510
Fax: 402-309-2580
English Authorization for Release of Protected Health Information
Spanish Authorization for Release of Protected Health Information
HIPAA Individual Rights Forms
Our HIPAA Privacy Notice describes member/insured’s rights with respect to the protected health information (PHI) we maintain. All requests about these rights need to be made in writing using the PHI forms.
Protected Health Information Forms
Claim Forms
English Dental Claim Form (fillable PDF)
Spanish Dental Claim Form
Ameritas Vision Claim Form (fillable PDF) - for Vision Perfect plans, Dental plans with LASIK, FUSION plans and Dental plans with Exam Only benefit.
Spanish Ameritas Vision Claim Form
EyeMed Vision Out-of-Network Claim Form
VSP Vision Out-of-Network Claim Form
Total Vision Accidental Loss of Sight Claim Form
SoundCare Claim Form - for hearing care plans.
Enrollment Forms
Use our enrollment forms to enroll, change your name, add/drop dependents or waive coverage.
Choose from Dental/Vision, Dental Only or Vision Only. If your plan is High/Low or Triple Option, choose one of those forms and be sure to select which option you want. We also have Spanish versions of our two most popular Dental/Vision forms.
Dental/Vision
Dental/Vision High/Low
Dental/Vision Triple Option
Dental Only
Dental Only High/Low
Dental Only Triple Option
Vision Only
Vision Only High/Low
Vision Only Triple Option
Spanish Dental/Vision
Spanish Dental/Vision High/Low
State-Specific Enrollment Forms
Dental/Vision - Montana
Dental Only - Montana
Vision Only - Montana
Dental/Vision - New Hampshire
Dental Only - New Hampshire
Vision Only - New Hampshire
Dental/Vision - Washington
Dental Only - Washington
Vision Only - Washington
State-Specific ADA Claim Forms
Some states require you to use the ADA Claim Form for paper submission of dental claims. If you have services performed in one of the following states, you must use the ADA form: GA, ID, IL, IN, KY, LA, MD, MN, MO, MT, NC, ND, NJ, NV, NY, OH, OK, SD, TN, TX, VT, WI, WY. This listing of states is subject to change due to state regulations.
ADA Dental Claim Form
New Jersey Application to Appeal a Claims Determination
You have the right to appeal our claims determination(s) or appeal an apparent lack of activity on a claim you submitted.
New Jersey Application to Appeal a Claims Determination
Dependent Status Forms
Exception to Dependent Child Definition
If you have a non-traditional dependent under your care, submit the form below to determine if they qualify for dependent status.
English Request for Dependent Child Exception
Spanish Request for Dependent Child Exception
Enroll Dependent Under Disabled Status
If your child is over the dependent age (as specified in your plan) and is considered fully disabled, have your child's physician complete this form.
English Statement of Health
Spanish Statement of Health
Maternity Dental Benefit Disclosure Form
If you or your dependent is pregnant and your policy includes the maternity dental benefit, complete this form.
English Maternity Disclosure Form
Spanish Maternity Disclosure Form
Producer Forms
To become appointed with Ameritas Group and to be compliant with HIPAA Privacy regulations, simply fill out our combined appointment application and business associate addendum. Included with the appointment application is the Direct Deposit Authorization Form, so you can have your commissions deposited directly into your bank account. Mail or fax a completed copy of the form an a copy of your license to the Group sales office nearest you.
Appointment Application/Business Associate Addendum
State Specific Appeals Rights
View the states that require state specific appeals rights information and forms.
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