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Delta Dental of Nebraska

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Forms and new client applications

New client forms
Direct Debit Authorization (ACH) form
NE Dental Employer application – small business
NE Dental Medica Employer application - small business
Benefit Manager Toolkit (BMT) Access form - client

Enrollment forms
Enrollment Eligibility/Update form
Enrollment Eligibility/Update form – Español
One-Time Eligibility Load Instructions form

Broker forms
Agency/Broker ACH Direct Payment Authorization form
HIPPA Designated Contact form
Agent of Record Assignment form - individual
Agent of Record Assignment form – group
Benefit Manager Toolkit (BMT) Access form - agency

Contact
Understanding Your Dental Plan
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HIPAA Privacy Notice
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Transparency in Coverage
Language Assistance
Notice of Non-Discrimination
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Delta Dental of Nebraska is a part of Delta Dental Plans Association. Through our national network of Delta Dental companies, we offer dental coverage in all 50 states, Puerto Rico and other U.S. territories.