Prepaid Dental Application

Dental Plan Enrollment

Enrollment form and payment must be received by the 15th of the month in order to begin coverage on the 1st day of the following month. When your enrollment is processed, membership confirmation will be e-mailed to you. You may make an appointment with your selected dentist at anytime after your effective date of coverage. Make sure to select a dental office when you enroll and upload your payment information prior to submitting your application. Please call 720-488-9892 if you have any questions. The required PDF payment form "Charge Card Authorization" can be found at the bottom of this page.

* Indicates required field

Name *

First

Last

Email *

Phone Number *

Employer / School *

Mailing Address *

Line 1

Line 2

City

State

Zip Code

Country

Gender *

Male Female

Social Security Number *

Date of Birth *

Dental Facility ID *

To select a dental office click here
Enter the ID# in the box to the left

Coverage Type *

Spouse *

First

Last

Date of Birth *

Child #1 *

First

Last

Date of Birth *

Child #2 *

First

Last

Date of Birth *

Child #3 *

First

Last

Date of Birth *

Child #4 *

First

Last

Date of Birth *

Upload Charge Card Authorization Form. See below. *

Max file size: 20MB

Agent *

Submit

Additional Required Forms

charge_authorization_form.pdf
File Size:	71 kb
File Type:	pdf

Download File

Dental Plan Enrollment ​

Additional Required Forms

Dental Plan Enrollment