To protect our associates and their families during the current health crisis, our associates are not in our office locations. We remain open for business, as most associates are working remotely where possible. Learn more about how we’re continuing to serve our customers during this time.
Have a dental emergency? Here is a list of dentists who are open and seeing new emergency patients during this time.
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.