More Accessible Forms!

SecureCare Dental has provided the following forms in PDF format for your convenience. To view these forms, you must have Adobe Acrobat Reader installed. If you don't have it, you can obtain it by clicking on the link below.



New Group Materials

	1.	To request a quote, click here.
	2.	Click on the Enrollment/Coverage Change Form in Administrative Forms below and print.
	3.	Click on the Employer Master Group Application in Administrative Forms below and print.
	4.	To learn about the Triple Choice Plans click here.

Dentist Directory

To find a dentist, please click here. For a complete dentist directory in English or Spanish, please request one here.

Please Choose State to Access Forms	State:  Arizona
01 Administrative Forms
ADA Claim Form	81 KB
Employee Certificate of Coverage	1007 KB
Employer Master Group Application (AZ)	243 KB
Enrolllment & Coverage Change Form (AZ)	77 KB
Enrollment & Coverage Change Form - Spanish (AZ)	105 KB
Group Insurance Policy	787 KB
Protected Health Information Release Authorization	23 KB
02 Plan Benefit Forms
Orthodontic Benefit (Non-insured)	92 KB
Plan 111 - Schedule of Copayments - Spanish	121 KB
Plan 111 - Schedule of Copayments	96 KB
Plan 120 - Schedule of Copayments - Spanish	114 KB
Plan 120 - Schedule of Copayments	100 KB
Plan 191 - Schedule of Copayments - Spanish	121 KB
Plan 191 - Schedule of Copayments	95 KB
03 Dentist Forms
ADA Claim Form	81 KB
General Dentist - Patient Copays - Plan 110	71 KB
General Dentist - Patient Copays - Plan 111	71 KB
General Dentist - Patient Copays - Plan 120	74 KB
General Dentist - Patient Copays - Plan 190	71 KB
General Dentist - Patient Copays - Plan 191	71 KB
General Dentist Contract	241 KB
Specialist - Patient Copays - Plan 110	74 KB
Specialist - Patient Copays - Plan 111	74 KB
Specialist - Patient Copays - Plan 120	74 KB
Specialist - Patient Copays - Plan 190	74 KB
Specialist - Patient Copays - Plan 191	74 KB
Specialist Contract	205 KB
04 Agent & Broker Forms
Online Agent Appointment Instructions	87 KB
Producer Marketing Agreement 010108	72 KB
SecureCare Dental Highlights	1630 KB
SecureCare Dental Plan Solutions 010108	1597 KB

back to top