Notice


October 20, 2020: Member and Dentist registration is currently unavailable. We are sorry for the inconvenience and thank you for your patience while we work to restore this feature.

Our Interactive Voice Response System (IVR) is operational 24/7 for self-service at 800-452-9310.

Dental Forms Library for Employers

Find the application or form that relates to your needs and easily download and print, or submit online.

Authorization Form Granting Access to PHI - Insured Clients (PDF, 3 pages, 52kb)

Authorization Form Granting Access to PHI - Self Funded Clients (PDF, 3 pages, 51kb)

Eligibility Enrollment Change Form (PDF, 2 pages, 22kb)
Use this form to submit new adds, changes, and terminations. 


COBRA Application 
(PDF, 1 page, 63kb)

Certification of Handicapped Child's Dependency Status
 
(PDF, 1 page, 13kb)
This form officially certifies the dependency status of a handicapped child. To be signed by the child's physician.