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Empire Dental Prime and Empire Dental Complete Employer Services

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Post-sale questions? Call Employer Services, a division of Customer Service, at 877-567-1799. Press 1 for Billing, 2 for Enrollment, 3 for Group Administrator Helpline. 
Log in to Anthem Dental Prime and Dental Complete Online Enrollment & Billing Tools
(log on to access online enrollment and billing reports). 
Use the forms below for Dental Prime or Dental Complete plans with effective dates before October 1, 2015. 
Employer Forms  
Click on the icons in the "Upstate" column if you are located in one of the following counties: Albany, Clinton, Essex, Fulton, Montgomery, Rensselear, Saratoga, Schenectady, Schoharie, Washington and Warren. For employers located in all other counties choose "Downstate”.  

Groups Implementation & Enrollment
Downstate
Upstate

Census Enrollment Spreadsheet

PDF Format

Group Administration Manual

PDF Format

PDF Format

 
Member & Group Forms
Downstate
Upstate

Membership Enrollment Form

PDF Format

PDF Format

Membership Enrollment Form – Spanish

PDF Format

PDF Format

Membership Maintenance Form

PDF Format

PDF Format

Authorization to Release Information

PDF Format

PDF Format

Authorization to Release Information - Spanish

PDF Format

PDF Format

Disabled Dependent/Michelle’s Law Application

PDF Format

Dental Provider Nomination Form

PDF Format

 
Claims & Additional Benefits Forms
Downstate
Upstate
Dental Claim Form 

PDF Format

International Emergency Dental Program Flyer  

PDF Format

PDF Format

International Emergency Dental Program Frequently Asked Questions 

PDF Format

PDF Format

 
Online Services
Downstate
Upstate
Online Capabilities Flier 

PDF Format

PDF Format

Online Enrollment Billing Reports User Request Form

PDF Format

PDF Format

Dental Employer Online Services Demo

Demo

Demo

Group Billing Forms
Downstate
Upstate

Monthly Fully Insured Billing Schedule

PDF Format

PDF Format

Automated Fully Insured ACH Authorization Form

PDF Format

PDF Format

Automated ASO ACH Authorization Form

PDF Format

PDF Format

©2017 Empire BlueCross BlueShield

Services provided by Empire HealthChoice HMO, Inc. and/or Empire HealthChoice Assurance, Inc., and/or HealthPlus, LLC., licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans, serving residents and businesses in the 28 eastern and southeastern counties of New York State. All external sites will open in a new browser window. Please view our Website Privacy Policy for more information.