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Request Form

Please select & click the APPLICATION you are applying for.

INDIVIDUAL
DOWNLOAD AND PRINT THE APPLICATION FOR MAILING OR FAX FOR FASTER APPROVAL

Online Application - Click Here
Secure Online Transaction

GROUP
DOWNLOAD AND PRINT THE APPLICATION FOR MAILING OR FAX FOR FASTER APPROVAL

Online Application Click Here
Secure Online Transaction

Individual application is for:
Individual
Individual & one dependent
Individual & Family

Group application is for:
Employee
Employee & one dependent
Employee & Family

You must be employed by a company that offers American Dental Care to it's employees and have 5 or more that participate in the plan.

NOTE: If your company does not offer American Dental Care and you would like them to, click here.

This plan is not insurance. The plan provides discounts at certain health care providers for medical services.
The plan does not make payments directly to the providers of medical services. The plan member is obligated
to pay for all health care services but will receive a discount from those health care providers who have
contracted with the discount plan organization.

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