DeltaCare Enrollment
 

Agent Information
If you do not have an agent, please leave this section blank.

Agent ID:


Agent Name:                                        Agent Phone Number:
       

Agent E-mail:

 

 

Applicant Information
Coverage subject to approval.  The application must be received by the 15th of the month prior to the requested effective date.

Requested Effective Date:

The application must be received by Wolfpack Insurance Services, Inc by the 15th of the month preceding the requested 
effective date.

SSN:
--

Email Address for Invoicing


First Name:                             Last Name:                                       Gender - Choose one:
                      

Phone Number:                      Date of Birth: mm/dd/yyyy
          

Address:


City:                                                    State:           Zip Code:
          
 


Provider Section
This is a dental HMO program.
You and your family must receive all treatment form the DeltaCare dental office you select.  
If you have not already selected a provider, please follow this link to search for DeltaCare Provider.  Please make sure you select the DeltaCare USA Network.

The directory is updated the first week of each month as additional panel dentists are included.  You may call the DeltaCare Customer Service Department at (800) 422-4234 for updates to the provider list.  If an office is closed to further enrollment, DeltaCare reserves the right to assign you to another dental office as close as possible to your home.  All members of your family must receive care from the same assigned network dental facility.

Contract Facility ID Number:          Facility Name:
                           
Six Digit Dental Office ID#

Dependent Information

Eligible dependents include your spouse and unmarried children to age 26.
 
  First Name Last Name (If Different) Gender Date of Birth
Spouse/Domestic Partner
Child #1
Child #2
Child #3
Child #4
Child #5

 
Select your Payment Option
Monthly auto draft Or Quarterly Premium Payment
Monthly automatic payment via automatic draft from your checking or savings account. (Provide the information below)
       If you choose Monthly automatic payment we will draft the initial payment from this account on the 15th of the Month prior to the effective date.
Quarterly Invoicing to the members email address listed above.  
      We will collect the first two months of premium at enrollment by a credit card payment.  After the first two months payment, we will mail you a Quarterly invoice.  A $3.00 billing fee will be added to each quarterly invoice. 


Monthly Automatic Payment from your Bank Account.
Monthly Drafts occur on the 15th of the month prior to the coverage month.

By selecting Monthly Automatic payment, I (we) hereby authorize Wolfpack Insurance Services Inc. to charge the application monthly dues for dental coverage to my account designed below.  I understand that coverage will only become and remain effective if there are sufficient funds at the time of the deduction.  I understand eligibility begins the first of the month following my initial deduction.  

I (We) acknowledge that the origination of ACH transaction to my (our) account must comply with the provision of U.S. Law and the Rules of the National Automated Clearing House Association. I (We) further acknowledge that I (we) have retained a copy of this authorization when I (we) signed it.
 
You hereby authorize and request Wolfpack Insurance Services, Inc. to debit funds from your account at the financial institution indicated, and credit the funds according to the above instructions. Funds need to be on deposit at the designated financial institution on the evening prior to the effective date of the ACH debit. In the event of an error, you authorize  Wolfpack Insurance Servcies, Inc to take any and all action required to correct the error.
 
You must notify Wolfpack Insurance Services, Inc. in writing if you would like to make any changes or to cancel the authorization.
You agree to indemnify and hold Wolfpack Insurance Servcies, Inc. harmless from all costs, including attorney’s fees, (to the extent permitted by law), damage or claims related to Wolfpack Insurance Services action in refusing payment of the item, including claims of any joint account-holder, payee, or endorsee, or in failing to cancel or process an item as a result of incorrect information provided by you.   Upon cancellation Wolfpack Insurance Services will collect any outstanding premium due.
 
By clicking Submit Form below, you certify that the information you have given on this ACH Debit Authorization Agreement for Direct Payments is complete, true, and submitted for the purpose selected above.

I also understand there cannot be any lapse in coverage in a 12-month period from the time of my enrollment.  I agree to comply with the terms outlined in the Combined Evidence of Coverage and Disclosure Form.  (My bank is authorized to make corrections if any should be necessary.)  Automatic draft failures are subject to a $15.00 fee.

Bank Name:                                                                                          Type of Account: Choose one, please
                    

ABA Routing number (First nine-digit number on left-hand bottom of your check):


Account Number (Second series of numbers on the bottom of the check:


 
Credit Card

When you select the Quarterly billing we collect the initial premium with a credit card payment.  

We will charge the credit card at the time of enrollment for the first two months of premium and the initial $5.00 enrollment fee.

Name on Credit Card:

Card Type (Choose one)

Card Number

Expiration Date
  
 

Terms and Conditions
I hereby understand and acknowledge that I am enrolling in the Wolfpack Insurance Services Trust group for DeltaCare
coverage under group 01675, plan 11B.  Benefit and plan information was reviewed from the DentalandVisionIns.com website,
Family Plan Section.  I agree to the terms and conditions of the plan.  
Click here to view a complete evidence of coverage for this plan.

We will send you a copy of the Evidence of Coverage for Plan 11B along with a wallet card for your use as confirmation that you are
enrolled.  The minimum enrollment period is 12 months.  Should you voluntarily cancel enrollment and subsequently desired to
re-enroll, all premiums retroactive to the date of cancelation (but not to exceed 12 months) must be paid before you can re-enroll.  If
you cancel after your initial 12 months enrollment period and wish to re-enroll you will have to wait 13 months from your last date of
coverage.

Premium rates renew January 1st of each year and I understand that I will be sent a renewal notice to the last known address on Wolfpack
Insurance Services systems.  I hereby authorize my medical or dental care institution or professional to release to a representative of
PMI, any personal, privileged or medical records information including, but not limited to, my patient records, charts, x-rays, diagnosis
histories, billing records, clinical abstracts, or copies of consultations.  The information authorized herein may be used for determination
of benefits, quality assessment, utilization review, grievance resolution or investigation or compliance with the PMI provider agreements
or local, state or federal laws.  This authorization is valid for the duration of coverage.

In addition to the rates shown below, there is a one-time enrollment fee of $5.00

Rates shown below are valid through December 31, 2020, and will renew 01-01-2023.

Monthly - One Person $34.20, Two Persons $60.70, Three Persons $89.10
Quarterly - One Person $102.60, Two Person $182.10, Three Persons $267.30

Click here to acknowledge you have read the above statement:
I agree to the terms and conditions of the plan