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Coordination of Benefits

If you or any other family member has other coverage that pays for your dental expenses in addition to GEHA, please complete the information below and select Submit Form to send this form by email to GEHA.

All fields are required unless marked as optional.

Employee or Annuitant Identification Data

To help us identify your account, please provide the following information.

First Name

Middle Initial (optional)

Last Name

GEHA Connection Dental Plus ID Number

Street Address

City

State/Province

Zip Code Please enter a five-digit ZIP Code.

Email Address By providing your email address, you agree to receive email news and information from GEHA. You have the ability to opt out from within any email communication you receive from GEHA.

Other Group Coverage Information

Are you or any other covered family member actively employed any place other than the federal government?

Yes

Family Member First Name (optional)

Family Member Middle Initial (optional)

Family Member Last Name (optional)

Employer Name (optional)

Employer Address (optional)

Employer City (optional)

Employer State (optional)

Employer Zip Code (optional)

Are you or any other family members covered under any other group health or dental insurance plan?

Yes

Policyholder First Name (optional)

Policyholder Middle Initial (optional)

Policyholder Last Name (optional)

Relationship to GEHA Member (optional)

Is this other coverage (optional)

Single coverage

Family coverage

Is this person (optional)

Employeed

Retired

Retirement Date (optional)

Other Carrier Name (optional)

Other Carrier Phone Number (optional)

What is the policy number, contract number or group certificate number of other policy? (optional)

Please list family members eligible for other group coverages below (optional)

Effective Date (optional)

FEHB Plan Name (optional)

FEHB Code (optional)

Signature

By entering my name below, I certify that the information furnished by me is true and correct to the best of my knowledge and belief.

Member Signature

Today's Date