Eligibility Maintenance Registration Form

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I'm Already Registered…


		As a Broker/Consultant
		As a Dentist
		As an Employer
		As a Member

I Need to Register…


		As a Broker/Consultant
		As a Dentist
		As an Employer
		As a Member

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Eligibility Maintenance Registration Form

Primary Contact

Full Name:*
E-mail Address:*
Company Name:*
Group Number:
Phone Number:*
* Required field.

Terms of Use


I, an authorized representative for the “Company” designated above in “Primary Contact,” hereby authorize registered staff members to utilize the Delta Dental of Oklahoma Eligibility Maintenance online service. I acknowledge my company will be responsible for notifying Delta Dental of Oklahoma in writing of any changes in staff or company information. At any time, I may send written notification to Delta Dental of Oklahoma to exclude staff members or end their utilization of the Delta Dental of Oklahoma Eligibility Maintenance online service.
NOTE: Brokers/Consultants wishing to register for Eligibility Maintenance must contact your Delta Dental of Oklahoma Broker Support Representative for an authorization form.