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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: 
01 Administrative Forms
ADA Claim Form  100 KB
Employer Master Group Application  217 KB
Enrollment Form - Dental & Vision  310 KB
Enrollment Form - Dental Vision Life STDI Acc  769 KB
Protected Health Information Release Authorization  42 KB
02 Dental Plan Benefit Forms
AZ100 Schedule of Copays ENGLISH  62 KB
AZ100 Schedule of Copays SPANISH  77 KB
AZ300 Schedule of Copays ENGLISH  62 KB
AZ300 Schedule of Copays SPANISH  77 KB
AZ400 Schedule of Copays ENGLISH  62 KB
AZ400 Schedule of Copays SPANISH  77 KB
AZ500 Schedule of Copays ENGLISH  62 KB
AZ500 Schedule of Copays SPANISH  77 KB
NV Non Network Benefits Payments ENGLISH  54 KB
NV Non Network Benefits Payments SPANISH  62 KB
NV100 Schedule of Copays ENGLISH  62 KB
NV100 Schedule of Copays SPANISH  77 KB
NV300 Schedule of Copays ENGLISH  62 KB
NV300 Schedule of Copays SPANISH  77 KB
NV400 Schedule of Copays ENGLISH  62 KB
NV400 Schedule of Copays SPANISH  77 KB
NV500 Schedule of Copays ENGLISH  62 KB
NV500 Schedule of Copays SPANISH  77 KB
Plan 100 Schedule of Copays ENGLISH  63 KB
Plan 100 Schedule of Copays SPANISH  78 KB
Plan 101 Schedule of Copays ENGLISH  61 KB
Plan 101 Schedule of Copays SPANISH  76 KB
Plan 130 Schedule of Copays ENGLISH  62 KB
Plan 130 Schedule of Copays SPANISH  77 KB
Plan 131 Schedule of Copays ENGLISH  61 KB
Plan 131 Schedule of Copays SPANISH  76 KB
Plan 140 Schedule of Copays ENGLISH  62 KB
Plan 140 Schedule of Copays SPANISH  77 KB
Plan 141 Schedule of Copays ENGLISH  61 KB
Plan 141 Schedule of Copays SPANISH  76 KB
Plan 150 Schedule of Copays ENGLISH  62 KB
Plan 150 Schedule of Copays SPANISH  77 KB
Plan 151 Schedule of Copays ENGLISH  61 KB
Plan 151 Schedule of Copays SPANISH  76 KB
SecureCare Dental Covered Codes  44 KB
03 Vision Plan Benefit Forms
Davis Vision & EPIC Hearing Brochure  691 KB
SecureCare Vision Plan Summary  149 KB
Vision Value Added Features - English  949 KB
Vision Value Added Features - Spanish  640 KB
04 Certificates & Policies
AZ Dental Certificate  493 KB
AZ Dental Policy  164 KB
AZ Vision Certificate  324 KB
AZ Vision Policy  164 KB
HIPAA Notice of Privacy Practices  54 KB
NV Dental Certificate  420 KB
NV Dental Policy  135 KB
NV Vision Certificate  302 KB
NV Vision Policy  135 KB
05 Dentist Forms
ADA Claim Form  100 KB
General Dentist Contract  230 KB
Provider Schedule of Copays AZ100  60 KB
Provider Schedule of Copays AZ300  60 KB
Provider Schedule of Copays AZ400  60 KB
Provider Schedule of Copays AZ500  60 KB
Provider Schedule of Copays NV100  60 KB
Provider Schedule of Copays NV300  60 KB
Provider Schedule of Copays NV400  60 KB
Provider Schedule of Copays NV500  60 KB
Provider Schedule of Copays Plan 100  60 KB
Provider Schedule of Copays Plan 101  59 KB
Provider Schedule of Copays Plan 130  60 KB
Provider Schedule of Copays Plan 131  59 KB
Provider Schedule of Copays Plan 140  60 KB
Provider Schedule of Copays Plan 141  59 KB
Provider Schedule of Copays Plan 150  60 KB
Provider Schedule of Copays Plan 151  59 KB
SecureCare Dental Covered Codes  44 KB
Specialist Contract  230 KB
06 Agent & Broker Forms
SecureCare Dental Plan Provisions  166 KB
07 SecureOne Plan Forms
01 - Using your SecureOne Plan  154 KB
02 - SecureOne Dental Plan Summary  201 KB
03 - SecureOne Vision Plan Summary  238 KB
04 - SecureOne Hearing Plan Summary  217 KB
05 - SecureOne Arizona Chiropractic Plan Summary  134 KB
06 - SecureOne Nevada Chiropractic & Alternative Medicine  141 KB
07 - SecureOne Prescription Plan Summary  196 KB
08 - SecureOne Orthodontic Plan Services  193 KB
09 - SecureOne Individual Plan Summary  158 KB
10 - SecureOne Arizona Brochure  468 KB
10 - SecureOne Nevada Brochure  491 KB
11 - SecureOne Membership Fees  74 KB


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Dental and Vision Insurance Underwritten by American National Life Insurance Company of Texas    Galveston, Texas.
Life, Short Term Disability, Accident, Critical Illness, Cancer, Limited Medical and FlexCare Hospital & Medical Insurance Underwritten by Standard Life and Accident Insurance Company   Galveston, Texas.
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