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"It's for you..."

Please enjoy this custom video that we made just for you. Having a powerful marketing strategy that brings in multiple patients on a consistent basis should neither be expensive nor complicated. Let us create, run and optimize powerful ads for you on various social media platforms and Google.

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Employee Enrollment Form
Indiana
241-11075 03/20SG.EE.20.IN 12/19
To Be Completed By Employer
Requested Effective Date of Coverage/Date of Change / /
Group Name Policy Number
Date of Hire
Reason for Application
New Group Plan
New Hire
Life Event/Date _____
Annual
Status Change ______ Open
Dependent Add/Delete Enrollment
Change Name/Address
Late
Part time to Full time Enrollee
Waiving Coverage
Termination
Other ___________________________
Employee Type
(Check all that apply)
Active COBRA State Continuation
Start dt ____ / ____ / ____
End dt ____ / ____ / ____
Hourly Salary
Union Non-Union Retired
Other ______________________________
Position/Title
Hours Worked per week
Salary $ _____________
Required only if Life, STD,
or LTD Plan based on salary
A. Employee Information
If you are waiving all coverage, please complete sections A and B.
Last Name First Name MI Social Security Number
Address Apt # City State Zip Code Home Phone
Cell Phone
Date of Birth
/ /
Sex
M F
Marital Status Single Divorced Married Widowed
Work Phone
Language Preference, if not English _________________________
Email Address:
Do you use tobacco?
1
Yes No
If yes, are you currently participating in a tobacco cessation
program or do you intend to join one? Yes No
Primary Care Physician
2
Existing Patient? Yes No
Physician First & Last Name ______________________________
Address ______________________________________________
ID#
———————————
————
Primary Care Dentist
3
Dentist First & Last Name _______________________________
ID# _________________________________________________
Existing Patient?
Yes No
(DO NOT STAPLE)
To speed the enrollment process, please be thorough and fill out all sections that apply.
B. Waiver of Coverage
Declining coverage due to existence of other coverage:
Spouse’s Employers Plan Individual Plan
Covered by Medicare Medicaid
COBRA from Prior Employer VA Eligibility
TriCare
I (we) have no other coverage at this time
Other _____________________________________
I understand that by waiving coverage at this time, I
will not be allowed to participate unless I qualify at a
special enrollment period or as a late enrollee, if
applicable, or at the next open enrollment period.
I decline all coverage for:
Myself
Spouse
Dependent Children
Myself and all dependents
Date Employee Signature if waiving all coverage
Coverage Provided by “UnitedHealthcare and Affiliates”:
Medical coverage provided by UnitedHealthcare Insurance Company, All Savers Insurance Company or UnitedHealthcare of Kentucky, Ltd.
Dental coverage provided by UnitedHealthcare Insurance Company
Life, Short-Term Disability (STD), Long-Term Disability (LTD) Insurance coverage provided by UnitedHealthcare Insurance Company
Vision coverage provided by UnitedHealthcare Insurance Company

FREE until you get your first patient

Book a call with me now

Covid-19 is effecting everybody. People don’t want to leave their houses. But what if they could understand that their oral health can actually help them in preventing various sicknesses. What if, as they should, people felt that their oral health was a necessity?

At Word of Mouth Dental Marketing, we love what we do, and we are very good at it. Google SEO and Analytics, Facebook Ads Website Optimization, Email Marketing – you name them and we use them to create powerful but simple hands-off funnels that filter quality patients directly into your practice.  While we are not experts in dentistry, we are experts in dental marketing and have an intimate knowledge of internet marketing. We partner with our clients, combining expertise for the greatest results. As you saw in the video, communication is one of our strengths and we use it to your benefit in order to create ads that work specifically for your business.

With all of the fluff out of the way, I want to be clear that we understand you can’t know whether our services work until you experience them for yourself. Because of this, we don’t charge you any money for our expertise until you get your first paying patient as a result of our services. Sure, you’ll pay the base cost for the ads since Google and Facebook don’t offer the same courtesy, but you won’t pay a dime for our expertise until you actually get results first.

Good luck finding that deal with another marketing company. 

We value your time, and we’re prepared to back that up.

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SEO for growth certified
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