Member Application Request

Individuals can enroll here for Dental Programs administered by American Dental Professional Services (ADPS). Click here to learn more about the Dental Programs we offer.
You can download a membership application to print and mail to ADPS. You may also complete the form below and submit your application to us electronically. If you have any questions about completing your application, please call us at 1-888-540-9488 or click here to submit your question or comments.
Upon receipt, we will promptly process your membership application and mail an ID card to you.

A NOTE ABOUT DISCOUNT HEALTHCARE PROGRAMS

Our discount programs are NOT health insurance policies and the program does not make payments directly to the providers of health services. The program member is obligated to pay the provider for all health care services that the member will receive, but, the member will receive a pre-negotiated discount from the providers listed in the network, in accordance with the specific pre-negotiated discounted fee schedules. These programs provide discounts at certain locations for health services. The discount program does not guarantee the quality of the services or products offered by the providers.
If the member cancels the membership within the first thirty (30) days after receipt of the discount card and other membership materials, the member shall receive a reimbursement of all fees paid. If the member cancels the membership after a period of one month, the reimbursement of membership fees will be prorated.

* indicates required fields.

Title	Mr.MissMs.Mrs.Dr.
First Name *
Last Name *
Company
Address 1 *
Address 2
City *
State *	AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
Zip Code *
Telephone
Fax
Email
Marital Status	SingleMarriedDivorced
SSN
Gender *	MaleFemale
Date of Birth *
Association or Group Name (if applicable)
Agent Name (if applicable)
General Agent Name (if applicable)
Program*	Dental Care AdvantageDental Care Advantage Senior ProgramOrthoCareDental Care Advantage - Affiliate
State in which coverage is desired	AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
Dependent 1 Name
Dependent 1 Social Security Number
Dependent 1 Gender	MaleFemale
Dependent 1 Birth date
Dependent 2 Name
Dependent 2 Social Security Number
Dependent 2 Gender	MaleFemale
Dependent 2 Birth date
Dependent 3 Name
Dependent 3 Social Security Number
Dependent 3 Gender	MaleFemale
Dependent 3 Birth date
Dependent 4 Name
Dependent 4 Social Security Number
Dependent 4 Gender	MaleFemale
Dependent 4 Birth date
Dependent 5 Name
Dependent 5 Social Security Number
Dependent 5 Gender	MaleFemale
Dependent 5 Birth date