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Blue Access for Employers

BlueCare® Dental HMO- Center Selection/Change Form

    
 

To receive BlueCare Dental HMO benefits, you must receive care from a dentist in the BlueCare Dental HMO network. If you're selecting a dentist for the first time or changing dentists, complete the fields below.
  Asterisks (*) indicate required fields.

 
Member Information
  Employee Full Name*  
  Member ID Last 4 Digits*   (Member ID number is found on ID Card)
  Date of Birth*

  		      (MM/DD/YYYY )
  Address*  


 
    City*    State*  Zip*    
    Daytime Phone*    Evening Phone*     
    E-mail      
           
  Dental Center Information   
   
Current Center
  
Number
  
 
New Center*
   Number
Name
 		  
    Employer Name*      
   
Reason for Center Change:
        New home address  
        New dental office added to network  
        Dental office closer to home or workplace  
        Dislike present office (please state reason)

  
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