The Dental Plan That Makes "Cents"


ADMS Dentist Selection Form

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Fill out the following form completely and hit submit below.

Last Name: First Name: M.I.
SSN: School/Dept:
Address: Apt. #  
City: State: Zip:
Home Phone: Work Phone:
 

Who's
Covered		 Employee Spouse Child Child Child
 
Last
Name:
 
First
Name:
 
D.O.B:
 
Sex:
 
Dentist
Selected:
 
Dentist ID:
 
Location:
 
Employee
ID #:
 
 

Member Only
Member and one Dependant:
Member and Family:

        

By hitting the submit button above, I acknowledge that I have read and agreed to the following:

  • I apply for membership in the A.D.M.S. Dental Plan for myself and for any eligible dependents listed.
  • I and my eligible dependents shall adibe by the provisios of coverage in the Group Membership Service Agreement and Schedule of Benefits under which we are enrolled.
  • I authorize any physician, hospital or other facility to disclose to A.D.M.S. any medical information relating to individuals specified in this applicaton.
  • I understand that misrepresentation in answering the questions on this application, or nonpayment of premium or co-payment, may result in cancellation of membership.
  • I understand that is my responsibility to report to HISD & A.D.M.S. any change in the eligibility of myself or my dependents.