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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
AZ Dental Certificate  493 KB
AZ Dental Policy  164 KB
AZ Vision Certificate  324 KB
AZ Vision Policy  164 KB
Employer Group Master Application (AZ)  430 KB
Employer Group Master Application (NV)  402 KB
Enrollment & Coverage Change Form (English) AZ  142 KB
Enrollment & Coverage Change Form (English) NV  138 KB
Enrollment & Coverage Change Form (Spanish) AZ  142 KB
Enrollment & Coverage Change Form (Spanish) NV  141 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
Protected Health Information Release Authorization  42 KB
02 Dental Plan Benefit Forms
Plan 100 - Schedule of Copays ENGLISH  61 KB
Plan 100 - Schedule of Copays SPANISH  84 KB
Plan 101 - Schedule of Copays ENGLISH  61 KB
Plan 101 - Schedule of Copays SPANISH  87 KB
Plan 101, 131, 141, 151 Non Network Benefits ENGLISH  53 KB
Plan 130 - Schedule of Copays ENGLISH  61 KB
Plan 130 - Schedule of Copays SPANISH  82 KB
Plan 131 - Schedule of Copays ENGLISH  61 KB
Plan 131 - Schedule of Copays SPANISH  93 KB
Plan 140 - Schedule of Copays ENGLISH  61 KB
Plan 140 - Schedule of Copays SPANISH  83 KB
Plan 141 - Schedule of Copays ENGLISH  61 KB
Plan 141 - Schedule of Copays SPANISH  93 KB
Plan 150 - Schedule of Copays ENGLISH  61 KB
Plan 150 - Schedule of Copays SPANISH  82 KB
Plan 151 - Schedule of Copays ENGLISH  61 KB
Plan 151 - Schedule of Copays SPANISH  75 KB
Plan AZ100 - Schedule of Copays ENGLISH  61 KB
Plan AZ300 - Schedule of Copays ENGLISH  61 KB
Plan AZ400 - Schedule of Copays ENGLISH  61 KB
Plan AZ500 - Schedule of Copays ENGLISH  61 KB
Plan NV100 - Schedule of Copays ENGLISH  61 KB
Plan NV100, NV300, NV400, NV500 Non Network Benefits ENGLISH  53 KB
Plan NV300 - Schedule of Copays ENGLISH  61 KB
Plan NV400 - Schedule of Copays ENGLISH  61 KB
Plan NV500 - Schedule of Copays ENGLISH  61 KB
03 Vision Plan Benefit Forms
SecureCare Vision Plan Summary  149 KB
Vision Value Added Features - English  949 KB
Vision Value Added Features - Spanish  640 KB
04 Dentist Forms
ADA Claim Form  100 KB
General Dentist Contract  230 KB
Provider Schedule of Copays Plan 100  60 KB
Provider Schedule of Copays Plan 101  59 KB
Provider Schedule of Copays Plan 130  59 KB
Provider Schedule of Copays Plan 131  59 KB
Provider Schedule of Copays Plan 140  59 KB
Provider Schedule of Copays Plan 141  59 KB
Provider Schedule of Copays Plan 150  59 KB
Provider Schedule of Copays Plan 151  59 KB
SecureCare Dental Covered Codes  44 KB
Specialist Contract  230 KB
05 Agent & Broker Forms
SecureCare Dental Plan Provisions  166 KB
06 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


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