ENROLLMENT FORMS and INFORMATION

How to use our forms

 

Note: To ensure timely processing of your form, please be sure to follow the instructions precisely below.

 

All of our forms are in portable document format (pdf) and you must have Adobe Acrobat Reader installed on your computer or other device to view them.

 

Step 1:  Locate the form you need directly to the left.  Please print the form for manual completion.

 

Step 2:  Complete the form making sure to fill in all necessary and requested information.   

       It is extremely important that you read each form thoroughly and provide all additional requested information to accompany the form, such as receipts and/or EOBs.  

       If the form or any additional requested attachments are incomplete, the form can not be processed until all requested information is received.

 

Step 3:  Mail, Fax, or Scan the completed form and all requested supporting documentation (if any) to: 

 

Integrity Administrators, Inc.

ATTN:  Administration Department

P.O. Box 13128

Sacramento, CA 95813-3128

 

Fax  916.921.3383

 

Email:  admin@integrityadmin.com

Employers use these forms to define group information and member eligibility for DentAssure Dental Plans. 

Members use this form to enroll for DentAssure Dental Plans.

NAONE

Members use this form to enroll for a Self Funding Account.

This document summarizes the three Dental Plans. 

Phone 800.562.9383    Fax 916.921.3383

© 1996-2017  Integrity Administrators, Inc.  All Rights Reserved

Integrity Administrators, Inc.

 

EXCELLENCE IN THIRD PARTY ADMINISTRATION

HIPAA COMPLIANCE

In compliance with privacy laws, please submit this form if you wish to allow any person, other than yourself, permission to contact us about your benefits or claims.   

This document outlines the HIPAA Privacy Rule and includes our policy on how we use Protected Health Information (PHI). 

For use by NAONE Members only

Because not all employers offer the same types of health plans,

some of these links may require you to login

to obtain your specific health benefits. 

Members use this form to enroll for Direct Deposit of payments

for Medical / Dental claims.

Members use this form to enroll for electronic Explanation of Benefits (EOB) statements.

This button links to the NAONE Dental enrollment forms.

This button links to the NAONE Dental brochures.

Members use this form to enroll and declare your election/options of benefits for your Flexible Spending Account.

Members use this form to email questions for more help.