To complete this form, you’ll need all, or some of the following:
- Member last name and first name
- Member email address
- Plan name
- Plan type
- Dentist information
- Dentist specialty
- Practice name
- Practice address
We want to process your form as quickly as possible, but missing information will cause delays in processing.
* Prior to completing this form, please contact Customer Service at the number on your Member ID card to verify that the dentist you want to nominate is not participating with your dental plan.