To enroll in the one of the Argus National Plans, please fill out the form below.If you have any questions please contact our Enrollment Team at (844) 641-5156.Click here for information on the Argus National Plans. For Provider Search please click here.Step 1 of 2 - Member Information50%Enrollment Instructions Complete the entire application which begins below and be sure to include all eligible dependents (family members you wish to include under your coverage)Gender*MaleFemaleDate of Birth*Year20202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Month123456789101112Day12345678910111213141516171819202122232425262728293031First Name*Last Name*Street Address*Apartment #City*State*AlabamaCaliforniaDistrict of ColumbiaGeorgiaIllinoisIowaKentuckyMichiganMinnesotaMississippiNebraskaNew JerseyNew MexicoNorth DakotaSouth CarolinaTennesseeWest VirginiaWisconsinWyomingZip Code*Email* Home Phone*Dentist NameHow did you hear about us ?*Select OneAgentDentistE-HealthEmailSearch Engine (Google, Bing, Yahoo, etc.)FacebookTwitterReferralOtherOther*AgentsConnelly JohnSilvey JoshStoner JohnWalton BrendaWhaley BeverlyWiley YvonneCooley DustinKhan AsifSmith GaryMeyers JasonGuerriero RobertSalmAon CecilOliver SherifBerrios ManuelSunderman TimStevens JamieWeidner JamesPiccione MaryannLane MarquiseLinderman WilliamMartin JerryDr Cowan Cosmetic DentistryDr. Kulangara Smile Design LithiaHorner AlanLeal KaterinBenton GwendollenBeebe KennethGoheen DavidWright III AlbertKrause RichardBraun MitchellPowell MicheleHarting GailFranzoni JeffreySoriano RicardoMercado JeffreyMatalucci GaryPartazana LouBruce RobertDr Georgy Ideal DentistryStrelow JodiVidal NikkiTrail DawnDeegan DarleneCode BrianSumrall ErnieRousmaniere DaleGjestland NormanWilkinson EugeneRothsman WallaceRoberts DanielPerry AnthonyEdouard StevensIsrael StevenReichmann RichardDr Fellner Lake Wales DentistryThornburg ClydeGibbons GeorgeMosley JulieBlizman DonnaHanke BradleyAhern KeriJoglar-Gaya JoseKellner KennethBielak JarekSanchez AbelBurkett JamesBarnes SteveBurton MichelleBurns CynthiaJohnson-Gomez CarolynSchumacher VictorKevlin PauletteMcCarthy WilliamBarrineau ThomasLombardi LucindaBarrow ValerieRayfield JohnElder PhilipWhidden RobWareheim JamesSaland LeslieHaney DanielUrquia WalterGreen GabrielSenior RoderickDr. Monticciolo & Fares Family DentistryKunish RobertInsurance Marketing AtlasNichols ToshaHamilton RobertBustinza JessicaHack ElizabethSanders PatrickDr Angelov Dentique DentalWike DeniseRieger RichardDuff KassandraQuigley ElizabethSmith RobertOlsen RebeccaMay ScottFuchs CurtisSenson ArnelDuke LoydMandino AndrewDaza LuisAlvarez LuzSisic VildanaAdcock MichaelBarton MichaelRojas OscarWest NenaWysocki TimothyHusk CarolynWortham CarolLombino FrankThomason LarrySullivan ChristineBendtsen GeorgeGjika EneaRange DennisGarofalo JosephTaylor DavidWojan DieterRorem HollyPendry JessicaHaass DavidMeredith MichaelPerez AlbertWilliams ClaudetteBuffano PhilipHotvedt AngelaCoursey JessicaDiaz HectorDr Parasher Caring DentistLang ChristopherNeal DiannaWashington LennyCarmenate JeannieFullwood DeborahGecewicz WilliamHeller LeonardSineno Jr JosephRyan JacquelineJackson NevilleAndre DavidKerker RaymondCannella JosephTomecko JosephJackson MichaelAtwood SusanSerna RodolfoO Hara ThomasBrent A. J.Carter Jr CharlesVance HerschelJarrett OwenDr Duvart & Desinor Bright NowReimann AmyO Sullivan KevinMassrock JacklynBonaparte BarbaraPersaud DianaStambler Dr. SilviaPutiri SalvatoreAccount HouseCrews BryanPariseau RobertHealth Group MCCKonopka KimberlyWinters JeffreyWait DelosEvers ChristianeSchake RamonaHicks BrianStrawbridge JaneWatts KevinKozic SvetlanaDr. Walker and Vu DHS WestshoreRukstele AnthonyRider FredericMcCurdy PaulPeters JohnCode JordanBrown JesseBlunt DavidBruckman AdamOcampo LidicisTaylor RobertVasquez FrancisMinkler AllenErd LisaHaney danCarrasquillo JavierKlima RichardPapich JosephGonyou ChristopherRusche BarryPhelps PamelaMiles ChristopherJuster FloydDr Bivens DA Sun CityHager WilliamBushey RichardSmith WilliamTapia-Rosa JoseMcClellan LarryFerris AllynO Brien JillPullara StevenCallan JamesRobinson MarkWhite RosaAgency LLC Mai InsuranceHill ConstanceEdwards CarolynBiltis JackLaracuente CarmenRamirez RaulInsurance ZimzoomMiller AngelaPooler ErinAlexander DawnBullerman LindaFloyd SheilaDr Walker - Hsu DHS NorthdaleGonzales MabelDr. Monticciolo Family DentistryLeitner Mary JoyPoole-Schwappach MichelleRogachevsky EileenJohnson NormanKerner AllisonVimond FrederickPratt PatriciaNolan AndrewCook DawnRoberts BlakeKasten AndrewChacon CesarHenderson WalterStruckhoff AdamDonnelly TimothyLeyva NancyFrierson JamillaAli FazalJean-Jules DivensonLogan ShanesiaYoung BradyGearhart MarkBlanco AngelicaFinkbeiner DennisLichtenfels RyanSerrano VitaliaDonovan StevenJohnson KimberlySnider BrendaDr Carter DA Plant CityHamrick LarryDr. Parikshak Premier DentalPatterson DoreenRuthstrom ScottVinokur MitchellGilford WilliamModglin RichardBelcher StevenKrystyen ElizabethDoerges DavidMcDade MarkHill Sharlenecom Dentalinsurance.Persky JeffreyCoggins BarbaraRoach AngelaGrant JamesVidal-Curtis ChariGuenst KennethWheeler ScottCuster JohnGardner CraigBenson AlanVolosin CharlesBurke Bridges ToniKing WilliamRobert Hurley EHealthRodriguez FernandoJames GregorySmither BradleySwink JamesLinkin JamesWatkins FrankErnest CynthiaKeller KarenBaron RonVentolo GerardZimmerman HowardCrews BryanMarkese DanielGreen CoraMiller TammyStephenson JosephBanks GeorgeLargel MonicaCiko JohnCorcoran JulieRuby JeffreyCrawford OliviaPreuss BernieDickinson GeannineJenkins GeorgeBrown DonaldMitchell BrooksCapehart GeorgePearson KennethMazzapica, Jr PaulGrigoriadis KathrynClifton SteffanieDr Weber Family Dent HernandoBeyerlein BradleyJones JenniferWhite PerryGiuffra JamesDr Phelps Caring DentistHayden MarkKessel PhilipThomas LelandReagin ThomasPatrick JamesBrowning BrettBridges AngelaO Neill BradleyPaz NeilLevy EstherSaidi MondherDr Fox Palm Tree DentalMartinez MarilinDMD Dr WelchSutherland RobertSteinman JamesPutman ShaunPaglino VincentKaplan StephenThomas SuzanneCollins PeggyGill AndrewStevenson RobertAnderson KristenKrones WilliamPowell DossDiRaimo RobertKimmel JohnTownsend DwayaneBerry ThomasBrooks LouisLewis DawnBushko HeidiCurrier ClaytonKeehn RobertSilver DavidMartinez VictorEmery KarenSantonelli GayleDr. Almerico Woodside DentalRatchford Robert (Andrew)Roberts JulieMilagros RitaDr Ruiz Crown DentalLonardo RobertWohlberg MelissaHowes DaleMoncarsz AlanMcCauley JamesJefferson QuintinFisher JohnLee HungParadise GeraldPatton AnthonySnyder MarkCollazo VirmarieKennedy KurtisFessler CaseHoskinson LauraMiller CliffordBrown CatherineGosline ClaudiaHernandez CharlesStracener MarvinMulvey RichardHerr AndriaClark JeffreyMilligan TimothyVogel PeterDacre PaulMcDowell FrederickWurstle CarrieBurrows JamesDr Weiner DA New TampaBall TimothyMonfred DominicCraig RebeccaReiff DeborahStrehl RichardHoeneisen RayKratz RosePerkins JohnWillmore RebeccaDr Mueller DA TampaFord JeffreySchumaker HaroldMajersky JohnBaldwin LowrySchreppel GayleMonroe RobertMoses JosephTaylor CarolynStoffer Jr. JamesSaidi Ben (Mondher)Perez JohnRodriguez JorgeRuth RobertqBraun JayLinares LarrySpinuso GabrieleSands BarclayMilonas ThomasVice SpencerCampbell JayBozanich SamSandford Jr JohnCarr WilliamDr Burchell - Dr Weinstock DHSDiaz AdrianaThe Villages Smile DesignMannello DanielVasquez Castro BelkysMorrel JesseSmith WilliamBurnett DemarcusStrijewski AlexParrish AllanBeckman BarbaraDr Cohrn and Pellosie Heritage DentalRamentol AlfredoChickk KennethOlson DesireeO Sullivan ShawnJohnston RogerVertich MarkVadovsky KylaPomales (PRS Consulting) PedroLopes MarcioKent KennethDzurick CarrieMcGhee MelissaHamilton MaryMartinez ShelbyAnderson ShireeRollinson WilliamGonzalez AnnieCastro CarlosEmpert RichardSollner RichardLeCain AnitaThaxton JosephNgo LyDillow DavidBartley DavidBallard DanielParker BrettRosenkrantz HowardStagliano KerryCox AndrewGonzalez NathanaelDaidone FrancisMorin ThomasBartlein RandallMayer ThomasUrban MaryKamimae ScotBarreto CharlesFolb PaulitaGiles JohnSeivers TimBerg BrianArata SilSeivers TimothyRabinowitz ArnoldStephens MichaelLangsford KarenLangsford Lima KarenDissault DanHenry DonnaMontermini DavidAssociates PNRReckner MichaelStiller TiffanyKlonowski ScottCariglio PaulGroup HylantPoli RobertOberlin DanielDuczak GeorgeHernandez RigobertoCohen CathyTeran Ruiz JoseBarrlentos JoseLlinas-Ochoa ManuelaBastardo RafaelO Carroll JamieSmith EricBaker GlenNoel TimothySakamoto WayneFiorella JohnHenry FrancisHernandez-Melgar NidiaChang LeilaVermaak SteveBlizman DonnaUpdyke JeffreySepulveda LourdesRichardson Robert ScottHullinger MatthewMoncell WayneNoreen DennisPines KarenSmith JerryWolf PatriciaNadolski LawrenceMoya WilliamRice JamesLluch IrmaRamos IvonneQuiara CarlosGutierrez GloriaMesser RoyVan Iseghem KerryAyers RandyHursey Jr PrestonMiedema JustinHenkel JonathanChalmers JohnQuire TysonSnowman CatherineJean-Paul DonnaGonzalez JackelineCallahan DanaHecht JoeHornacek StevenPerez-Correa EdgardoPurvis JohnThomas AlexMefferd AndrewSpotts JenniferBress AllenBaste JorgePhillips JohnPerez BelisaAlmonte RitaThornhill ThomasJean Francois FrankyGoldberg FrankRusso JamesCharles EnocLaMonde Jr PierreDuval NadineMilligan TimothyCram NormanMacDonald LaurieCorominas WandaBean AnnLambrecht PhillipJones CourtneyOrlova NataliaGuerrero ClaudiaGuerrero BettyBress AllenFebres GuillermoMena Martinez Jose LuisMartinez-Perez JanetArteaga GiomarTorres HugoVargas LuisDurango ElsimarHidalgo LauzauthHernandez DorisCoradin GraceArteaga GiomarMartinez OrquideaAgudelo Guerra OscarGrullon MariaMateo ZoraydaRodriguez MarcelaYancent EgmaHartzler RyanAnthony TonyBahr JasonZiskie GerardPolt EliseHernandez DorisMatos WandaMogollon MariaGomez Riveros LuisArana MariluMcIntyre JohnRowe BrianaHaeger CarlChecca MathewLiedtke SabraOwen GaryRobinette MichelleTurner BryanMaurice ChristopherSorensen PeterMarona MichelleBaird JeremyPhilipp MarkButler BrianParker ToniaLoustaunau JoaquinGannon JosephGoldfield IraStrong BiragoMitchen JenniferBarbone MichaelLopez CarlosVillota AlexandraCross TimothyBalakrishnan Girija SarikaBowen NicoleKennedy ShannonMendez IsaacSmith StephenMontero RoqueRodriguez MonicaAraque MarisolCarter JulieEscudero GinetteLores Parra NorvenTornes LuisFeliciano LuisMejia GuerlineGarcia BarbaraDuque LuzPuche SusanaFranco AngelRios AvelinaPeterson CelesteRomeus YvesBedsole SidneyAmador FelixJayne RichardDelahanty MartaFraser DennisCrook SandraBowen RichardYoungblood DavidUrena Delvalle OfradisParker RichardHemming MaureenOey SeeBlocker II AnthonySimeon ElizabethPiedrahita AstridCova Figueroa JesusTrabal GlendaFeliciano CarlosMehler DavidGarcia WilliamEck GregoryPorto DominicCastrillo AliGonda DawnCavin DennySamuelson LuAnnStingone LisaOtero MelvinMarcano HenryPerrow ChadNazariego NaylibethJimenez MariaParada MarthaPeters TracyWilliamson LindaAgreda JhonnyVillamarin SaraTest TestTest TestSteve Test Steve TestWilliams-Von Zopf JeanPittman SusanWichman MatthewLindstein AdamMarrullier MarshaMayer AshleaAwad MohammedGomez FelixLoCicero MichelleSullivan DavidLarson JodeneFrederique CherlyDe Moya AngelicaRink MonteDe Alba FelipeTemeyer StephenFranco AlbaLobdell DeborahAdelusi HenryGill JaniceZaid DannyLamarre FrantzSegarra DanelisArriaga AdelfaDoss KarenMahoney ThomasDaugherty ScottCasimir JeanNazaire GertySantiago KarenNucete NedelsonHolmes WillieDega BridgettJohnson WilhelminaVidair RichardJordan DanielLarson AlanPhan HoaiDarnell BenjaminSchumer RobTurbay MariaDavis LoNeaseHouck DarrenColey EsmieVelieri SusanGoff BrendaDeSouza AnthiaWokasch MelissaBooth NeilBrunet MigdaliaRitter MichaelCedeno YusetRoig Martinez RaydelDavis LarrieKinnaman RobertLinnemon RonPaules SherriGill JaniceWolff MichaelGullickson DarrylDavis LarrieLabrecciosa JohnDilling GregDenHouter JoyBell MarieSkinner RogerMathwig RogerDahlquist AmyKavouklis MichaelGionis StephenNagel DavidJordan DonaldGossage Jr JohnKohanim DariusRhodes RickKatsaitis DimitriosSlayton RobertMenendez FrancisPaino TomAdam SaheedBoice JasaenAcevedo MarisolRomeo SamuelScaglione JackHolley SharonKavouklis MaggieVega RichardMacchione AnthonyMaxson CarlStaebler MichaelHumpal JessEarp JeremyJohnston JahnnaMay CathyDedmon LarryMerz CathyRandazzo JamesKinder LuAnneSource*Select OneRX AdvantageSearch EngineWebsiteE-HealthTBTFacebookeBayDentistOtherDependents: Eligible dependents include your spouse and /or unmarried children from birth to 19 years of age, or 25 years of age if a full-time student or fully dependent on you for support.National Plan Certificate of Coverage Member GuideI am applying for dental coverage and by my initials below, I understand this dental plan is a (1) year non-refundable program. I authorize the dentist who has rendered services to me or members of my family to make available to Argus Dental & Vision my dental records, photocopies or information regarding such services to the extent permitted by law. If information is not complete and your signature is not present, the application will not be processed. Any person who knowingly and with intent to injure, defraud or deceive any insurer, files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree.By placing my initials in the textbox, I constitute this as my online signature :*Individual RatesValueStandardPreferredIndividual$9.94$18.95$27.94Individual & Spouse$19.89$37.89$55.87Individual & Child(ren)$25.32$48.22$71.12Individual & Family$38.74$73.78$108.83*For monthly billing, your account will be debited or charged by the 15th of each month for one month’s premium plus a $1 monthly service charge. NOTE: A $35 one-time enrollment fee applies to your first year of enrollment which includes the $3 NCOA membership fee.Coverage Type*IndividualIndividual + SpouseIndividual + ChildFamilyPlan Type*ValueStandardPreferredBilling Frequency*MonthlyYearlyDependent DetailsDependent TypeFirst NameMiddle NameLast NameDate of BirthGender SpouseChildMaleFemale National Plan - Value Price: $0.00 National Plan - Standard Price: $0.00 National Plan - Preferred Price: $0.00 National Plan - Value Price: $0.00 National Plan - Standard Price: $0.00 National Plan - Preferred Price: $0.00 National Plan - Value Price: $0.00 National Plan - Standard Price: $0.00 National Plan - Preferred Price: $0.00 National Plan - Value Price: $0.00 National Plan - Standard Price: $0.00 National Plan - Preferred Price: $0.00 Enrollment FeeThis is a one time enrollment fee. Price: $35.00 Total Billing Today for National Plan $0.00 Payment TypeCardEcheckAuthorize.net EcheckCredit Card*American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20192020202120222023202420252026202720282029203020312032203320342035203620372038 Expiration Date Security Code Cardholder Name eCheck Name on Account Bank Name Routing Number Account Number CheckingSavingsAccount TypeBy clicking the button below, I authorize Argus Dental & Vision, Inc. to charge my credit card or bank account for the initial payment plus enrollment fee, if paying monthly I also authorize a charge on the 15th of each month for the monthly premiums plus a $1 monthly service fee.Review and Submit {all_fields}
