Insurance

Open to All Dental & Vision Benefits PPO &/or HMO

Insurance

Here we will provide a list of our approved insurance carriers.

Co- payment is due at the time the services are rendered. Billing arrangements may be made

Comp Benefits, Ameritas Group, First Ameritas Life Insurance Co of New York, Western Dental Services, Blue Cross & Blue Shield of California, + others Children now covered to age 26 for Ameritas Free Choice & PPO

Before making an appointment always ask if the provider is still contracted with either the DHMO or Ameritas Group PPO.

Always ask for a treatment plan in advance of any service to make sure you are being charged correctly.

Dental & Eye Care Insurance with PPO option All 50 States & DC

click here for forms you would need: 1199, Bank Drafft, Credit Card, & PostalEASE

click here to view or download Disclaimer OPM

Enrollment Application for Dental & Vision

Fusion PPO with Free Choice of Providers

both Dental & Eye Care available in all 50 States & D.C.

Dental HMO with Vision in specific areas

[for enrolled clients you may request changes

in coverage or make a payment here]

name as it appears on your pay check:
Social Security Number
Primary Email address-if you do not type in we will not have
Employing Agency or Retired From
Home Address 1:
Home City:
Home State:
Home Zip code & plus 4 number:
Home Phone:
Home Fax
Home Email
Pull down the Dental & Vision Plan You Want?:
Employer Name & Location or Retired from which agency?
Work Title
Work Street
Work City
Work State
Work Zip
Work Area Code
Work Phone
Work Ext if applicable
Work Email
Subscriber/Member/Employee Date of Birth Format 11/02/1970
Spouse Name
Spouse Date of Birth Format 01/01/1947
Child(rens) Names & Date of Birth
Plan Requested>Type in: i.e. DHMO 550V, HO, PPO E1, etc.
DDS Office Code # ? for Dental HMOs Only
Premium Dollar Amount
Select How You Are Paying the Enrollment Fee?
I understand that Fraud by me will effect my coverage CHECK REQUIRED_YES	Yes
Enrollment Fee $20 can't by Payroll Deduction other status i.e. ICE Member
Select to Expedite(& how) or to wait for Coverage?
Premium Mode :payroll, credit card, Quaterly, [semi & annual only available with HMO type in mode
Credit Card Type (only VISA & MC) or none?
Name on Credit Card
Credit Card Number
Credit Card Expiration Date
Credt Card Security # .last 3 #s on back of card
Credit Card Billing Address if different
If paying by Bank Draft Enrollment Fee or to Expedite then input 9 digit routing number
If paying by Bank Draft input your account # from your financial institution> Bank
How many dental & vision brochures may we mail for the people you work with?
Are you an APWU Member select Yes or No
Additional Family Member(s) DOB & SS# to add. Premium will be that of a single adult additional. They do not come on the same as normally covered children
Additional Information on other Coverage Requested Will Be Provided
Comments or Questions?

All new Postal Employees will have an increase in premium of $1.00 per pay period if paying by Payroll Deduction because of substantial increases in the trustees banking fees this does not effect any other premium mode. For Fusion PPO or any of the Dental HMOs

American Marketing Administrators, Inc.

Administrator Since 1980

Billing questions, plan changes, you've moved & other concerns: info@fedvp.com

23901 Calabasas Road Suite 2014
Calabasas, CA 91302-3307
Voice 818-223-9750 800-300-PLAN, FAX 818-223-8147

alternate fax when main # is busy 818-992-4438