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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

Membership

Status

General Dentist

Arvada (Dr. Moss)
Arvada (New Impressions)
Aurora (Dr. Malushev)
Aurora (Dr. Bowden)
Aurora (Tower Road)
Aurora (Hanu Dental Care)
Aurora (Dr. Joo)
Aurora (Dr. Fahmy)
Aurora (Prospect Ave.)
Aurora (Blue Mesa Dental)
Boulder (28th St.)
Boulder (Dr. Martin)
Boulder (Bright Now!)
Boulder (Dr. Schaffer)
Brighton (Platte River)
Broomfield (Dr. Marogil)
Broomfield (Dr. Mata)
Castle Rock (Bright Now!)
Castle Rock (Dr. Zirker)
Castle Rock (Dr. Houser)
Castle Rock (Shadow Rock)
Castle Rock (Dr. Moroni)
Centennial (8100 S. Quebec)
Centennial (Dr. Christ)
Centennial (Dr. Bravo)

Colorado Springs (Dr. Rodriguez)
Colorado Springs (Bright Now!)
Colorado Springs (Blue Mesa Dental)
Colorado Springs (Dr. Brower)
Colorado Springs (Bright Now!)
Colorado Springs (Dr. Camerino)
Commerce City (E. 62nd Ave.)
Denver (Dr. Yahnian)
Denver (Bright Now!)
Denver (Dr. Elliott)
Denver (Dr. DeWitt)
Denver (Bright Now!)
Denver (Dr. Randolf)
Denver (Dr. Sakamaki)
Denver (Newton Street)
Denver (Dr. Wachuta)
Denver (Dr. Madden)
Denver (Accord Dental)
Denver (Dr. Kye Lee)
Denver (Greentree)
Denver (Cherry Hills)
Denver (Ulster St.)
Denver (Dr. Dougherty)
Englewood (Dr. Kuljis)
Englewood (Dr. Cowen)

Englewood (Dr. Case)
Ft. Collins (Bright Now!)
Ft. Collins (Drs. Wuerker & Green)
Ft. Collins (Dr. Murphy)
Ft. Collins (Dr. Fischer)
Ft. Collins (Clear Creek)
Ft. Collins (Dr. Allen)
Golden (Dr. Wachuta)
Golden (Golden View)
Greeley (Dr. Gomez)
Greeley (Dr. Jamison)
Greeley (Drs. Hatch & Johnson)
Greeley (Dr. Brown)
Highlands Ranch (University Park)
Highlands Ranch (Bright Now!)
LaSalle (Dr. Bender)
Lafayette (Dr. Winnicki)
Lafayette (Dr. White)
Lakewood (Bright Now!)
Lakewood (Dr. Milausnic)
Lakewood (Dr. Caldwell)
Lakewood (Dr. Schroeder)
Lakewood (Dr. Martinez)
Littleton (Old Town)
Littleton (Easter Ave)

Littleton (Dr. Preston)
Littleton (Prestige Dental)
Littleton (Dutch Creek)
Littleton (Dr. Kempton)
Lone Tree (Dentistry at Crest)
Longmont (Bright Now!)
Longmont (Dr Brown)
Longmont (Hover St)
Loveland (Bright Now!)
Parker (Dr. Fulton)
Parker (Parker Smiles)
Parker (Dr. Hale)
Pueblo (Dr. Villalon)
Pueblo (Dr. Roberts)
Pueblo (Dr. Saunders)
Pueblo (Gentle Touch)
Pueblo (Dr. Graves)
Thornton (Eppinger Blvd.)
Westminster (Dr. Moss)
Westminster (Bright Now!)
Wheat Ridge (Sante Fe)
Windsor (Dr. Bruhin)
Windsor (Windsor Dental)

New Patient

Employee Information

Last Name

First Name Initial

Marital Status

Gender

Birth Date

Home

Street

City

State

Zip

Phone

Work

Employer

Street

City

State

Zip

Phone

Num Employees

Dependents

Spouse Information

Last Name

First Name Initial

Birth Date

Gender

Work

Employer

Street

City

State

Zip

Phone

Num Employees

Insurance

Has Dental

Company

Dental Type

Additional Dependent Information

Relationship

Last Name

First Name Initial

Birth Date

Gender

Relationship

Last Name

First Name Initial

Birth Date

Gender

Relationship

Last Name

First Name Initial

Birth Date

Gender

Relationship

Last Name

First Name Initial

Birth Date

Gender

Relationship

Last Name

First Name Initial

Birth Date

Gender

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)