For your convenience, all of our forms on this site are current and ready for you to print and send to us. When accessing or downloading online forms, you agree to release, indemnify and hold harmless First Ameritas Life Insurance Corp. and/or its subsidiaries for any damage or liability encountered from using these forms. Please remember to keep only the most current First Ameritas forms on file.
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
P.O. Box 81889
Lincoln, NE 68510
Or fax it to the Privacy Office at 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
To submit a claim, please open the claim form PDF you need below, print it, fill it out, sign it and mail it to the address on the form. If it's a fillable PDF, open and type in your information, then print, sign and mail.
English Dental Claim Form (fillable PDF)
Spanish Dental Claim Form
First Ameritas Eye Care Claim Form - for Vision Perfect plans, Dental plans with LASIK, FUSION plans and Dental plans with Exam Only benefit.
EyeMed Eye Care Out-of-Network Claim Form
VSP Eye Care Out-of-Network Claim Form
Total Vision Accidental Loss of Sight Claim Form
SoundCare Claim Form - for hearing care plans.
Enrollment Forms
Getting great coverage begins with enrollment in your company's First Ameritas insurance plan. You may use our enrollment form to enroll, change your name, add/drop dependents or waive coverage.
All you need to do is open one of the enrollment form PDFs below, print it, fill it out, sign it and mail it to the address on the form. If it's a fillable PDF, open and type in your information, then print, sign and mail.
Choose from Dental/Eye Care, Dental Only or Eye Care Only. If your plan is High/Low, choose the Dental/Eye Care High/Low form, and be sure to select which option you want. We also have Spanish versions of our two most popular Dental/Eye Care forms.
Dental/Eye Care (fillable PDF)
Dental/Eye Care High/Low (fillable PDF)
Dental Only (fillable PDF)
Eye Care Only (fillable PDF)
Spanish Dental/Eye Care
Spanish Dental/Eye Care 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, OH, OK, SD, TN, TX, VT, WI, WY. A PDF of the form is provided below. You may print, fill out, sign and mail it to the address shown on the form. 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
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, please have your child's physician complete this form.
English Statement of Health
Spanish Statement of Health Maternity Dental Benefit Disclosure Form
If you or your dependent is pregnant and if your policy includes the maternity dental benefit, please complete this form.
English Maternity Disclosure Form
Spanish Maternity Disclosure Form
COBRA Election of Insurance Continuation
If you are eligible for a continuation of dental or eye care insurance coverage, complete, sign and return this form to your company's benefits representative.
Election of Insurance Continuation Form
Producer Forms
We'd love to have you join the First Ameritas family. But first things first: you'll need to be licensed and appointed with us. (Some states require brokers to be pre-appointed before presenting a quote to a client.) To become appointed with First Ameritas 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.
Appointment Application/Business Associate Addendum
Once you've completed and signed the form, mail it or fax it, along with a copy of your license, to the Group sales office nearest you.
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