To enroll and complete a paper enrollment form HERE and you may email, fax, or mail to the UUP Benefit Trust Fund.

Fax: 1-866-559-0516 Mail: Benefit Trust Fund , PO Box 15143, Albany, NY 12212-9954 Email: Benefits@uupmail.org

The DeltaCare®USA DHMO plan is being offered to UUP-represented employees as an alternative dental option. In addition to the original Delta Dental PPO plan, DeltaCare®USA DHMO is an HMO-type dental program that is designed to encourage regular visits to the dentist by having no copayments on most diagnostic and preventive benefits.

Please note that the DeltaCare® USA DHMO Program has provider deficiencies in the following areas: Alfred, Canton, Cobleskill, Delhi, Oneonta, Plattsburgh, and Potsdam. Delta is making every effort to contract providers in these regions.

Employee Information:

Dental Office Information:

Spouse \ Domestic Partner Information:

Dependent Children Information

Enter Dependent Children Information:   (HERE)

DEPENDENT #1

First name:
Last name:
Middle:
Delta Care USA Primary Dentist:
Dental Office ID:
Date of Birth:

DEPENDENT #2

First name:
Last name:
Middle:
Delta Care USA Primary Dentist:
Dental Office ID:
Date of Birth:

DEPENDENT #3

First name:
Last name:
Middle:
Delta Care USA Primary Dentist:
Dental Office ID:
Date of Birth:

DEPENDENT #4

First name:
Last name:
Middle:
Delta Care USA Primary Dentist:
Dental Office ID:
Date of Birth:

DEPENDENT #5

First name:
Last name:
Middle:
Delta Care USA Primary Dentist:
Dental Office ID:
Date of Birth:

DEPENDENT #6

First name:
Last name:
Middle:
Delta Care USA Primary Dentist:
Dental Office ID:
Date of Birth:

Enter Additional Dependent Children:   (HERE)

DEPENDENT #7

First name:
Last name:
Middle:
Delta Care USA Primary Dentist:
Dental Office ID:
Date of Birth:

DEPENDENT #8

First name:
Last name:
Middle:
Delta Care USA Primary Dentist:
Dental Office ID:
Date of Birth:

DEPENDENT #9

First name:
Last name:
Middle:
Delta Care USA Primary Dentist:
Dental Office ID:
Date of Birth:

DEPENDENT #10

First name:
Last name:
Middle:
Delta Care USA Primary Dentist:
Dental Office ID:
Date of Birth:

DEPENDENT #11

First name:
Last name:
Middle:
Delta Care USA Primary Dentist:
Dental Office ID:
Date of Birth:

DEPENDENT #12

First name:
Last name:
Middle:
Delta Care USA Primary Dentist:
Dental Office ID:
Date of Birth:

*Acceptance of Terms

YES! I Agree that submission of this form constitutes your consent to online enrollment and your commitment to enrollment in the DHMO program for one year. The enrollment year goes from January 1st – December 31st of each year. You will receive an email confirming receipt of this enrollment form. Please retain a copy of that email for you records.

* Required