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 members/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 of New York Vision Claim Form (fillable pdf) - for Vision Perfect plans, Dental plans with LASIK, FUSION plans and Dental plans with Exam Only benefit. 
Spanish Ameritas of New York 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, choose the Dental/Vision High/Low form and be sure to select which option you want. We also have Spanish versions of our two most popular Dental/Vision forms.
Dental/Vision (fillable PDF)
Dental/Vision High/Low (fillable PDF)
Dental Only (fillable PDF)
Vision Only (fillable PDF)
Spanish Dental/Vision
Spanish Dental/Vision High/Low

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

New York Confidentiality for Victims of Domestic Violence and Endangered Individuals
Your safety is important to us. Find information about your rights regarding domestic violence privacy and confidentiality.
Domestic and Sexual Violence Information

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

Producer Forms
To become appointed with Ameritas of New York 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 copy of the completed form and 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.