Access Dental Plan (Individual)
ComprehensiveHealthcareOptions.com, 12835 E. Arapahoe Rd Tower 1 Suite 330 Centennial, CO 80112
Phone: (303) 649-9311 Fax: (303) 649-9036 Toll Free: 1 (866) 870-6399
Membership Information
Plan
Blue
White
Red
Orange
Membership
Individual Membership
Individual + one dependant
Family Membership
Status
New
Renewal
General Dentist
Dr. Riegel (Arvada)
Wesminster Dental Health (Arvada)
New Impressions (Arvada)
Aurora Family Dentistry (Aurora)
Dr. Bowden (Aurora)
Tower Road (Aurora)
Hanu Dental Care (Aurora)
Dr. Joo (Aurora)
Dr. Fahmy (Aurora)
Prospect Ave. (Aurora)
Blue Mesa Dental (Aurora)
28th St. (Boulder)
Bright Now! (Boulder)
Platte River (Brighton)
Dr. Cope (Brighton)
Riverdale Dental (Brighton)
Dr. Marogil (Broomfield)
Dr. Mata (Broomfield)
Dr. Houser (Castle Rock)
Shadow Rock (Castle Rock)
Vogl Dental Arts (Castle Rock)
Dr. Jones (Castle Rock)
Bright Now! (Castle Rock)
Dr. Zirker (Castle Rock)
Dr. Moroni (Castle Rock)
Park Meadows Dental (Centennial)
Dr. Christ (Centennial)
Smoky Hill Family Dental (Centennial)
Dr. Bravo (Centennial)
Dr. Blatter (Centennial)
Dr. Rodriguez (Colorado Springs)
Jade Dental (Colorado Springs)
Cheyenne Mountain (Colorado Springs)
Bright Now! (Colorado Springs)
Blue Mesa Dental (Colorado Springs)
Dr. Brower (Colorado Springs)
Bright Now! (Colorado Springs)
Dr. Camerino (Colorado Springs)
E. 62nd Ave. (Commerce City)
Dr. Yahnian (Denver)
Bright Now! (Denver)
Dr. Elliott (Denver)
Dr. DeWitt (Denver)
Dr. Quandt (Denver)
Bright Now! (Denver)
Dr. Randolph (Denver)
Dr. Sakamaki (Denver)
Newton Street (Denver)
Dr. Wachuta (Denver)
Dr. Madden (Denver)
Dr. Coombs (Denver)
CS Family Dental (Denver)
Accord Dental (Denver)
Dr. Kye Lee (Denver)
Greentree (Denver)
Cherry Hills (Denver)
Ulster St. (Denver)
Dr. Dougherty (Denver)
Dr. Pyne (Denver)
Dr. Ciner (Denver)
Dr. Kuljis (Englewood)
Dr. Case (Englewood)
Dr. Bodoni (Englewood)
Dr. Bevis (Englewood)
Dr. Cowen (Englewood)
Bright Now! (Ft. Collins)
Boardwalk Dental (Ft. Collins)
Dr. Murphy (Ft. Collins)
Dr. Fischer (Ft. Collins)
Clear Creek (Ft. Collins)
Dr. Allen (Ft. Collins)
Dr. Losacco (Georgetown)
Dr. Topelson (Glendale)
Dr. Wachuta (Golden)
Golden View (Golden)
Dr. Clifton (Grand Junction)
Dr. Bingham (Greeley)
Dr. Jamison (Greeley)
Dr. Thorne (Greeley)
Dr. Brown (Greeley)
University Park (Highlands Ranch)
Bright Now! (Highlands Ranch)
Dr. Bender (LaSalle)
Dr. Winnicki (Lafayette)
Dr. White (Lafayette)
Bright Now! (Lakewood)
Dr. Milausnic (Lakewood)
Dr. Chavez (Lakewood)
Dr. Caldwell (Lakewood)
Dr. Paswaters (Lakewood)
Dr. Schroeder (Lakewood)
Dr. Martinez (Lakewood)
Dr. Wise (Lakewood)
Old Town (Littleton)
Guaranteed Smiles (Littleton)
Dr. Lampert (Littleton)
Dr. Preston (Littleton)
Belleview Dental (Littleton)
Dr. Carlile (Littleton)
Dutch Creek (Littleton)
Dr. Kempton (Littleton)
Dr. Ambida (Lone Tree)
Dentistry at Crest (Lone Tree)
Bright Now! (Longmont)
Dr. Brown (Longmont)
Hover St (Longmont)
Dr. Schreiber (Loveland)
Bright Now! (Loveland)
Dr. Ziegler (Northglenn)
Stonegate Dental (Parker)
Soft Touch Dental (Parker)
Dr. Villalon (Pueblo)
Dr. Roberts (Pueblo)
Dr. Saunders (Pueblo)
Gentle Touch (Pueblo)
Dr. Graves (Pueblo)
Eppinger Blvd. (Thornton)
Wesminster Dental Health (Westminster)
Westminster Dental Arts (Westminster)
Bright Now! (Westminster)
Sante Fe (Wheat Ridge)
Dr. Bruhin (Windsor)
Windsor Dental (Windsor)
()
()
New Patient
Yes
No
Employee Information
Last Name
First Name
Initial
Marital Status
Married
Single
Gender
Male
Female
Birth Date
Home
Street
City
State
Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
Dist. of Columbia
Delaware
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
Montana
North CaroILna
North Dakota
Nebraska
New Hampshire
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South CaroILna
South Dakota
Tennessee
Texas
Utah
Virginia
Vermont
Washington
Wisconsin
West Virginia
Wyoming
Zip
Phone
Email
Work
Employer
Street
City
State
Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
Dist. of Columbia
Delaware
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
Montana
North CaroILna
North Dakota
Nebraska
New Hampshire
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South CaroILna
South Dakota
Tennessee
Texas
Utah
Virginia
Vermont
Washington
Wisconsin
West Virginia
Wyoming
Zip
Phone
Email
Num Employees
Dependents
Spouse
Spouse + 1
Spouse + 2
Spouse + 3
Spouse + 4
1 (No spouse)
2 (No spouse)
3 (No spouse)
4 (No spouse)
5 (No spouse)
Spouse Information
Last Name
First Name
Initial
Birth Date
Gender
Male
Female
Work
Employer
Street
City
State
Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
Dist. of Columbia
Delaware
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
Montana
North CaroILna
North Dakota
Nebraska
New Hampshire
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South CaroILna
South Dakota
Tennessee
Texas
Utah
Virginia
Vermont
Washington
Wisconsin
West Virginia
Wyoming
Zip
Phone
Email
Num Employees
Insurance
Has Dental
Yes
No
Company
Dental Type
PPO
DHMO
Indemnity
Other
Additional Dependent Information
Relationship
Child
Step-child
Parent
Other
Last Name
First Name
Initial
Birth Date
Gender
Male
Female
Relationship
Child
Step-child
Parent
Other
Last Name
First Name
Initial
Birth Date
Gender
Male
Female
Relationship
Child
Step-child
Parent
Other
Last Name
First Name
Initial
Birth Date
Gender
Male
Female
Relationship
Child
Step-child
Parent
Other
Last Name
First Name
Initial
Birth Date
Gender
Male
Female
Relationship
Child
Step-child
Parent
Other
Last Name
First Name
Initial
Birth Date
Gender
Male
Female
Referred By
Comments
Payment of Membership Fees
Please call (303) 649-9311 or (866) 870-6399 to pay your Membership fees. You may also mail your payment to Comprehensive Healthcare Options, 12835 E. Arapahoe Rd., Tower 1, Suite 330, Centennial CO 80112. Your membership is activated on the day we process your payment.
Terms
I wish to become a member of the Access Dental Plan. I understand the limitations, exclusions and requirements of the plan. I understand that the Access Dental Plan is not insurance. I agree to pay any and all costs in collecting all charges, including but not limited to attorney fees and court costs. I understand membership must be continuous; that membership is on an annual basis; and I may terminate coverage on any anniversary of my enrollment. I understand all fees for services are payable when the services are rendered. I understand that I am eligible for a full refund of membership fees within 30 days of purchasing the Access Dental Plan. I understand that, as a result of cancellation of this plan, my dentist will retroactively bill me for the difference in the amount payable under the plan and his/her services I received while I was a participant of the plan. I understand that participating providers, fees for services and membership fees may change periodically. I certify all information on this form is true.
Acceptance
(Please type "Accept" to accept the terms of this application)