2007-2008
Download printable forms below as needed:

• 07-08 Enrollment Packet (.pdf)
  This 8 page document is the enrollment mailing sent out in September 2007, minus the plan descriptions, which are posted below separately for your convenience. It contains everything you need to know about enrolling in the dental and vision plans.
  
  
• 07-08 Delta Dental Plan Description (.pdf) This is the plan description for our plan, called Delta Dental PPO Plus Premier.
  
  
• 07-08 EyeMed Vision Plan Description (.pdf) This is the plan description for our vision plan.
  
  
• Paper version of the dental and vision application form (.pdf)
  If you prefer, or if you are having technical problems with the online application, you may use this form to apply on paper.
  
  
• Authorization/Waiver form (.pdf)
  If you are applying using the paper form (above) or if you were unable to print the authorization/waiver while applying online, you may print and complete this version of the authorization/waiver form. This form must be mailed or delivered to GEO, 201 Student Union, UMass Amherst, 01003.

• 07-08 Payroll Deduction for Family Dental Plan Participants (pdf.) This form must accompany your signed authorization form and must be turned into the GEO office by October 10th at Noon in order to pay the $100 family dental plan premium using University payroll deduction. $20.00 will be taken out of 5 paychecks starting October 19, 2007. No late forms can be accepted.
  

• 07-08 COBRA Application (.pdf)
  If you were covered under the GEO dental plan and lose that coverage for any reason and are no longer eligible to renew it, then federal law guarantees you the right to extend your coverage for up to 18 months by paying the monthly premium yourself. This document contains additional information as well as the COBRA application itself. This is the 07-08 COBRA application--it should be used beginning October 1, 2007. The completed COBRA form should be mailed to 326 Middlesex House, UMass Amherst, 01003. No need to send payment with your form--you will be billed once your form is processed. Read more information about COBRA here.
  

• Frequently Asked Questions (.pdf)
  Get the answers to all of the most frequently asked questions here.
  

• 07-08 HIPPA Policy and Waiver Form (.pdf)
  HIPAA is a federal law that guarantees the protection of your private medical information (including such basic data as your Social Security Number). We can only release or obtain this sort of information with your permission. When you sign your GEO dental application, you are granting permission only for the plan administrator to release your application information to Delta Dental for the purpose of providing your coverage. If you should ever want to extend this permission -- if, for instance, you want to enable us to discuss your GEO dental coverage with a family member or with another health care provider -- we would need you to fill out this form naming anyone to whom you wish to grant the authority to access your information. Without this signed form, staff of the GEO Dental plan are only free to discuss your coverage with you and with Delta Dental.
  

• Memo to all Participants Regarding Important Information on the HIPPA Privacy Policy (pdf.) This document describes all policies and procedures in place to protect your privacy under the HIPPA legislation.
  

• Summary of Material Modification of UAW/UMass Dental and Vision Plan, Effective with 11/1/07 Policy
(.pdf) This document describes a change to the plans voted on by the UAW/UMass Dental and Vision Board of Trustees, slated to take effect 11/1/07. The change will enable those graduate student employees who are enrolled and who graduate to remain enrolled until the natural end date of the plan period they are enrolled in.