Administrative Guide — DENTAL

The Dental Program Administrative Guide was designed to assist campuses with the administration of CSU Dental Benefits. All necessary forms and contacts have been provided.

General Instructions
General instructions and information pertaining to the administration of dental benefits for the CSU.

Appendix A
This section contains the necessary enrollment forms.

  • Dental Plan Enrollment Authorization

  • Declaration of Domestic Partnership

  • Statement of Financial Liability for Domestic Partner

  • Domestic Partner Tax Dependent Certification Form

  • Domestic Partner Tax Dependent Cancellation Form

  • Affidavit of Eligibility for Economically Dependent Children
  • Appendix B
    Instructions for completing the Dental Plan Enrollment Authorization Form (STD-692)

    Appendix C
    Dental Plan Permitting Event Charts

    Appendix D
    Request for continued Dental Plan coverage and Direct Payment Authorization, or Termination of Enrollment Form

    Appendix E
    Continuation of coverage information and documents.
        Group & Sublocation Numbers
        Delta Dental Plan: COBRA Notice, COBRA Form
        PMI DeltaCare Dental Plan: COBRA Notice, COBRA Form

    Appendix F
    List of employee groups eligible for Enhanced Dental Coverage

    Appendix G
    CSU Benefits Officers

    Appendix H
    Directory of Dental Plan Contacts

    Appendix I
    Lecturer Benefits Revised Eligibility

    Appendix J
    Additions and Deletions Sheet for Administrators, Delta Dental Plan

    Content Contact:
    Benefits Insider
    (562) 951-4411
    Technical Contact:

    Last Updated: January 24, 2003

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