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 member/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
Ameritas Eye Care Claim Form (fillable PDF) - for Vision Perfect plans, Dental plans with LASIK 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 (fillable PDF)
SoundCare Claim Form

Enrollment Forms
Getting great coverage begins with enrollment in your company’s 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. Each enrollment form is a fillable PDF so you can also open it 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 or Triple Option, choose one of those forms, 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 
Dental/Eye Care High/Low 
Dental/Eye Care Triple Option 
Dental Only
Dental Only High/Low 
Dental Only Triple Option 
Eye Care Only 
Eye Care Only High/Low 
Eye Care Only Triple Option 
Spanish Dental/Eye Care 
Spanish Dental/Eye Care High/Low

State-Specific Enrollment Forms
State-specific forms are not available as fillable PDFs.
Dental/Eye Care - Montana
Dental Only - Montana
Eye Care Only - Montana
Dental/Eye Care - New Hampshire
Dental Only - New Hampshire
Eye Care Only - New Hampshire

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.
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.
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.
Maternity Disclosure Form

Producer Forms
We’d love to have you join the 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 Ameritas Group 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.