• 501. General Information
• 502. Current State-Sponsored Dental Plans
• 503. Responsibilities
• 504. Dental Plan Deduction Codes/Premiums
• 505. Employee Eligibility
• 506. State Dental Plan Restriction for Newly Hired State Employees
• 507. CCPOA Benefit Trust Fund Dental Enrollment
• 508. Dependent Eligibility
• 509. Intentionally Unused
• 510. Enrollment
• 511. Allowable Changes to Enrollment
• 512. Effective Dates
• 513. Re-Enrollment of Employees
• 514. Annual Open Enrollment Period
• 515. Continuation of Coverage While Off Pay Status
• 516. 120-Day Survivor Death Benefit for Continuation of Benefits
• 517. Retiring Employees
• 518. Cancellation/Termination of Dental Enrollment/Coverage
• 519. Consolidated Omnibus Budget Reconciliation Act (COBRA)
• 520. Document Completion
• 521. Dental Carriers/Benefit Information

• View all Section 500

  Attachments

• Attachment A - Dental Plan Enrollment Authorization (Std. 692)
• Attachment B - Dental Deduction Codes/Premiums
• Attachment C - Permitting Events Code Chart
• Attachment D - Affidavit of Eligibility
• Attachment E - HDB-34
• Attachment F - Dental Plan Direct Payment Authorization (Std. 696)
• Attachment G - Affidavit of Eligibility - Domestic Partner (DPA 680)
• Attachment H - Instructions for Completion of Dental Plan Enrollment Authorization (Std. 692)
• Attachment I - Examples of Completed Std. 692
• Attachment J - Delta Form 602A (blank form)
• Attachment J1 - Delta Form 602A (example)

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• Table of Contents

520. Document Completion

General Information

1. Use of the Dental Plan Enrollment Authorization Form (STD. 692)
   • New enrollments or re-enrollments
   • Authorized changes to current coverage
   • Cancellation of all coverage
   • Elections not to enroll in a Dental Plan
   • COBRA continuation (Use STD. 692 for Prepaid Plans)

   The completed STD. 692 is submitted to SCO within the prescribed time limit for normal processing. Do not use the STD. 692 to report any changes regarding the employee that are reported on a STD. 686, Employee Action Request (EAR). These would include social security number, date of birth, name, address, or agency and unit changes.

   Once an employee is enrolled, any corrections to a dependent name or date of birth should be noted in red on a photocopy of the most recent enrollment form and forwarded directly to the appropriate dental carrier. Do not send a copy to SCO or DPA. An employee should report address changes directly to their carrier.

   Note:

   If any alterations are made to the wording in Section D of the STD. 692 by either the employee or the personnel staff, the SCO will not process the document and it will be returned to the department.

   Attachment H provides a chart with instructions for the completion of each item on the STD. 692 for active, retired and COBRA enrollments. Attachment I contains examples of the STD. 692 and how it is completed when a permitting event has occurred. Refer to Attachment B for current dental rates information. Personnel Office staff are encouraged to make use of these valuable reference tools.

2. Multiple Transactions

   When the permitting event code, effective date, and permitting event date are the same, all transactions can be reported on one form. When any of these items are different it will be necessary to complete a separate STD. 692 to report each change. When submitting more than one STD. 692, each form should be numbered (in remarks section) based on the sequence of each event (i.e., 1 of 3, 2 of 3 and 3 of 3).

3. Ordering Enrollment Forms

   Enrollment (STD. 692) and Dental Plan Direct Payment Authorization (STD. 696) forms can be ordered through the Office of State Publishing, Department of General Services.