Total Amount of Payment
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