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Title Purpose Action
ACH for Dental & Vision Customers Based in NY

Use this form to request and authorize an agreement for prearranged payments via Automated Clearing House. For use in New York only.

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ACH for Dental & Vision Customers Based Outside NY

Use this form to request and authorize an agreement for prearranged payments via Automated Clearing House.

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Authorization to Release Health-Related Information

Authorize The Standard to release dental and/or vision insurance information to a designated recipient.

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Authorization to Release Health-Related Information (NY)

Authorize The Standard to release dental and/or vision insurance information to a designated recipient. For use in New York only.

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Authorization to Release Health-Related Information (Spanish - All states except NY)

Authorize The Standard to release dental and/or vision insurance information to a designated recipient. (Spanish)

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Authorization to Release Health-Related Information (Spanish - NY)

Authorize The Standard to release dental and/or vision insurance information to a designated recipient. (Spanish) For use in New York only.

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Dental Claim (All states except NY)

Use this form to report a treatment plan and to initiate a dental claim.

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Dental Claim (NY)

Use this form to report a treatment plan and to initiate a dental claim. For use in New York only.

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Dental Claim (Spanish - All states except NY)

Use this form to report a treatment plan and to initiate a dental claim (Spanish).

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Dental Claim (Spanish - NY)

Use this form to report a treatment plan and to initiate a dental claim (Spanish). For use in New York only.

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EFT for Dental & Vision Customers Based in NY

Use this Electronic Funds Transfer form to request and authorize a bank payment plan. For use in New York only.

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EFT for Dental & Vision Customers Based Outside NY

Use this Electronic Funds Transfer form to request and authorize a bank payment plan.

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Maternity Dental Benefit Authorization to Obtain and Release Information (All states except NY)

Authorize the release of medical information to The Standard for review for the Maternity Dental Benefit.

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Maternity Dental Benefit Authorization to Obtain and Release Information (NY only)

Authorize the release of medical information to The Standard for review for the Maternity Dental Benefit. For use in New York only.

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Maternity Dental Benefit Authorization to Obtain and Release Information (Spanish - All states except NY)

Authorize the release of medical information to The Standard for review for the Maternity Dental Benefit. (Spanish)

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Maternity Dental Benefit Authorization to Obtain and Release Information (Spanish - NY only)

Authorize the release of medical information to The Standard for review for the Maternity Dental Benefit. (Spanish) For use in New York only.

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