Forms

Member

Appeal Request Form
Online Form
Authorization For Disclosure of Protected Health Information
Download PDF
COBRA Continuation of Group Dental Coverage Form
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Dual Coverage Information Request Form
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Enrollment/Change Form
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Employer

COBRA Billing Designation Form
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COBRA Continuation of Group Dental Coverage Form
Download PDF
Employer Account Registration Form
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Enrollment/Change Form
Download PDF

Broker

Broker Account Registration Form
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Broker Client Access Form
Download PDF
COBRA Billing Designation Form
Download PDF
Employer Account Registration Form
Download PDF

Dentist

Appeal Request Form
Online Form
Credentialing Form
Online Form
Dental Insurance 101 - Patient Resource Card Request Form
Online Form
Direct Deposit Enrollment Form
Download PDF
Individual Product Materials Request Form
Online Form
Sale of Dental Practice Form
Download PDF
W-9
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