Member Request Form Use this Member Request form to provide information for the dentist you’d like to switch to. You can also refer a dentist to our network. Required Member information First name Last name Member ID or employer name Street City State Zip code Phone number Email address Email address Confirm email What kind of request do you have today? I'd like to... - None -Get a new ID cardChange my addressChange my dentistRefer a dentist What's your new address? Address City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle EastArmed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederate States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code What's your new dentist's information? Name Phone number Street City State Zip What dentist would you like to refer? Name Phone number Street City State Zip Submit Leave this field blank.