Please complete this form if you would like more information about dental plans or third party administration, or would like to be contacted by a company representative.

First Name:		Last Name		Title:

Email:

I am a: Prospective Client Subscriber Broker Dentist Group Administrator

Organization Name:

Address:	City:	State	Zip:

Phone:		Fax:

Subject

Message:

Healthplex Inc.

333 Earle Ovington Boulevard, Suite 300

Uniondale, New York 11553

Corporate Offices:	516-542-2200 or 1-800-468-0608
Web Support:	888-468-5171
Fax:	516-794-3186
Email:	info@healthplex.com

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