Part A - Applicant Information

*SSN:

*Last Name: Middle Name: *First Name:

*Gender: *Date of Birth: (mm/dd/yyyy)

*Address 1:

Address 2:

*City, State, Zip:

Phone Number:

Part B - Enrollment

*Enrollment Type:

*Enrollment Fee: Pricing Fee List

Were you refered by an Insurance Agent? Agent's Name:

Part C - Dependent Information

Last Name: Middle Name: First Name:

Gender: SSN: Date of Birth: (mm/dd/yyyy) Relation:

Part D - Terms and Conditions

I have read the information available in the Delta Dental Patient Direct brochure. In addition to the information provided therein, I 
understand that:

	1. Delta Dental Patient Direct is a discount dental program, not insurance, which entitles me to discounts only from
	   New Mexico participating dentists;
	2. Participating dentists, who are not employees of Delta Dental, independently elect to participate in 
	   Delta Dental Patient Direct and may join or decline to participate in the network at any time;
	3. Delta Dental of New Mexico makes no guarantees as to the size or scope of the Delta Dental Patient Direct provider  
	   network that will be available at the time dental care services are required;
	4. If, for any reason, you are not completely satisfied with Delta Dental Patient Direct you may request a full refund 
		of your initial and annual enrollment fee.  Delta Dental Patient Direct ID cards must be returned to 
		Delta Dental of New Mexico with a written request for the refund postmarked within 45 days of the date your 
		Delta Dental Patient Direct ID cards were mailed to you.  Refund entitlement applies only to individuals 
		enrolling in Delta Dental Patient Direct for the first time. Refunds, and the termination of eligibility for 
		Delta Dental Patient Direct discounts, apply to the primary adult enrollee and each individual who enrolled 
		with the primary adult enrollee.;
	5. Refund entitlement applies only to individuals enrolling in Delta Dental Patient Direct for the first time;
	6. Refunds, and termination of eligibility for Delta Dental Patient Direct discounts, apply to the primary adult
	   enrollee and each individual who enrolled with the primary adult enrollee;
	7. Patients are responsible for all communications with their dentists related to appointments and services, and for all
	   payments for dental care services received.

I Agree I Do Not Agree

Delta Dental Patient Direct^® Application

Back to Patient Direct Home

Step 1 of 4 - Complete Enrollment Form

Part A - Applicant Information

Part B - Enrollment

Part C - Dependent Information

Part D - Terms and Conditions

Delta Dental Patient Direct® Application

Back to Patient Direct Home

Step 1 of 4 - Complete Enrollment Form

Part A - Applicant Information

Part B - Enrollment

Part C - Dependent Information

Part D - Terms and Conditions

Delta Dental Patient Direct^® Application