Membership Enrollment Form

APPLICATION

Select Plan for New York Dental Insurance and Vision Discount Plan Application

MEMBER INFORMATION

TELL US ABOUT YOURSELF

DENTIST INFORMATION

FIND YOUR DENTIST

PAYMENT INFORMATION

CREDIT CARD,
DEBIT CARD
OR CHECK

CONFIRM

REVIEW AND AGREE

FIRST NAME*

LAST NAME*

STREET ADDRESS*

CITY*

STATE*

ZIP*

DATE OF BIRTH* (MM/DD/YYYY)

MARITAL STATUS*

SSN* (NO SPACES OR DASHES)

---
Why do we need this

HOME PHONE* (NO SPACES OR DASHES)

EMAIL ADDRESS*

REFERRED BY

CANCELLATION POLICY

For more information, please review our Cancellation Policy and Terms and Conditions.

To enroll on the 1st day of a given month, enrollment materials must be received by the 21st day of the previous month. Any person who includes any false or misleading information on an application for an Insurance Policy is subject to criminal and civil penalties.

Payment Method
Please select a payment method

Payment Due: 264.00

CREDIT CARD

Visa

MasterCard

Discover

NAME ON CARD

CARD NUMBER

EXP. DATE

CHECK

Check Payable to: Dentcare Delivery Systems, Inc.

Mail To:
Billing Department
Dentcare Delivery Systems, Inc.
333 Earle Ovington Boulevard, Suite 300
Uniondale, NY 11553

Your coverage begins on the 1st day of the following month as long as we receive your payment by the 20th. See Terms and Conditions for details.

You will be signed up once the payment is received.

Members will remain active unless member notifies Dentcare Delivery Systems, Inc. of their request to cancel prior to the renewal date. Understand that your credit card will be automatically charged for the appropriate annual renewal amount.

Sign Up