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First Name

Last Name

Phone Number

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State

Street Address

City

ZIP Code

2/5

Do you want to list any dependents?

Yes

Anyone 18 or older must sign up for their own benefit card. Those under 18 years of age may be added below as dependents.

Dependent Full Names Enter full names of dependents separated by commas or on separate lines

3/5

Do you already have a group ID?

Yes

Group ID (Enter your group ID above)

Are you interested in establishing a health savings account (HSA) compatible with this program through Health Equity?

Yes

4/5

Your digital benefit card is being generated and will display on the next page in order to save on your smartphone as a file or photo. Would you also like a physical card mailed to you?

Yes, please mail a physical card

No, just display a digital card to save on my smartphone

A physical card will be mailed to:

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5/5

You’ve enrolled! We’ve sent you an email with the information below, please check your Inbox or Junk Folder.

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If you’ve already been given a physical card, it’s now been activated. Just write your Group and Patient ID directly on the card.

Your Group ID is: [loading...].

Your Patient ID is: [loading...]

Please press or click on the digital card image below and save to your device as a file or photo.

Login above to search for dentists in your area and view the fee schedule.

Health Savings Account Information

As an added value, the Dental Benefit Program offers qualified patients a Health Savings Account (HSA) made available through HealthEquity. Establishing an HSA is a great way to help budget your money for dental work. HSAs are tax free, roll over each year and allow you to make monthly contributions from your existing banking account.

To learn more about the advantages of an HSA and to begin the simple application process click on the HSA link in the navigation bar after you have logged in.

Group ID#:
Patient ID#: