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BlueCare Dental HMO Information
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BlueCare^® Dental HMO- Center Selection/Change Form


To receive BlueCare Dental HMO benefits, you must receive care from a dentist in the BlueCare Dental HMO network. If you're selecting a dentist for the first time or changing dentists, complete the fields below.

Asterisks (*) indicate required fields.

Member Information
	Employee Full Name*
	Member ID Last 4 Digits*	(Member ID number is found on ID Card)
	Date of Birth*	(MM/DD/YYYY )
	Address*
	City*	State* Zip*
	Daytime Phone*	Evening Phone*
	E-mail

Dental Center Information
	Current Center	Number
	New Center*	Number Name
	Employer Name*
	Reason for Center Change:
		New home address
		New dental office added to network
		Dental office closer to home or workplace
		Dislike present office (please state reason)
	Comments