American Dental Plan Online Enrollment Form

Fill out the information below along with your credit card information and click the SUBMIT button at the bottom of the page. Or, you can complete the form, print and fax to (602) 266-0607, or mail to:

American Health Network
P.O. Box 44227
Phoenix, AZ 85064-4227

Make check payable to: American Health Network

Should you experience any difficulties, please contact Customer Service at (602) 265-6677.

(* Required Fields)

Last Name*	First Name*		Middle Initial
Email*
Street*			Apt #
City*	State*		Zip*
Daytime Phone	Date of Birth		Spouse
Employer/Assn
Dental Center Number*	Code
Dependents' Name(s)		Birthdates

I agree to all terms of membership*

Select Plan Type (Annual Membership Dues*):
*New memberships include $5 enrollment fee.

Send information about Optical Plan
Send list of participating Chiropractors

MasterCard VISA Discover $10 Monthly**

** Member Authorization: I wish to enroll in American Dental Plan Plus monthly Surepay account. I have enclosed $20 (includes bank set-up fee and first month's payment) with my application and authorize my bank to deduct $10 per month for a minimum of 12 months from my checking account. This applies to Plan Plus, Family Membership only.

Card Number* Expiration Date*
Printed name as it appears on the card*

Authorization signature _______________________________________ Date

I wish to Refer a Friend!