Patient Financial Application Form- Download English Version
Protected Health Information Disclosure Form- Download English Version - Authorización para el uso y divulgación de información confidencial de salud
Coverage to begin upon completion of application and acceptance by Plan Administrator or local representative.
Please call for an appointment at any of the listed Newport Dental Plan Provider Offices. You will be responsible for the co-payments listed for each procedure completed. These fees must be paid directly to the dental office where treatment is received.
You may renew coverage with Newport Dental at the prevailing rate and for the benefits available at the time your coverage expires. Notice of rates and benefits will be mailed to you at least 30 days prior to expiration of your coverage.