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Association Member Enrollment Form

Number of People Enrolling

How many people will you be enrolling?

Cost of Coverage
$39.95 + $55.00 (One-time Enrollment Fee)

Your Information

Sex

(mm/dd/yyyy)

I do not have an email address.

Family Information

Qualifying  Age:   A Dependent Child is eligible for dental coverage to the age of
At this age the Dependent Child will need to have their own individual membership/dental coverage.

Choose your Dentist

Facility Choice for Policy Holder:
Enter Zip Code
(Desired Facility location)

 

Comments

Terms & Commitment

General Dentist work is the Co-Pay price.  Specialist work is a 25% Discount.   There are NO Waiting Periods once your dental plan goes into effect, NO Dollar Caps, and Pre-Existing Conditions covered immediately.


SG-GROUP-EF


 

Payment Information

Payment type
Choose Monthly Draft Date

 

(Name on card) First name
Last Name
Billing Address
City
State Zip Code
Account Type  
Bank Name
Routing Number
Account Number
Credit Card Type
Credit Card Number
Exp. Date
CCV
Comments
How did you hear about us?

 

Payment Authorization

Total Amount of Payment $94.95 Price includes 55.00 setup fee

I hereby authorize Healthcare National Marketing, Inc. (HCNM, Inc.), the administrators for National Association For Medical And Dental (NAFMD) to debit the account for the first month's membership dues and enrollment fee as noted above.  I understand that the amount of my association membership dues will be automatically debited from my account each month thereafter.

SafeGuard Dental Plan Enrollment Form (Florida)

Please return form to your Benefits Coordinator. Choose a general dental office (facility number) of your choice for each eliglble family member from the SafeGuard directory of Participating Dentist. Failure to do so may result in delays in receiving dental care. If your first provider facility selection in not available, SafeGaurd will process your second selection.

Benefits Coordinator Use Only

Group Name NAFMD, Inc.
Group No. 5752196