Refer a Dental Provider

If you were unable to find your dentist of choice, use this form to refer him or her to the Principal Plan Dental. Each applicant is reviewed with respect to utilization profiles, malpractice coverage, history, licensing, and sanctions. Accepted providers are continually monitored to ensure a quality network.

All required fields have to be completed in order for us to process your referral.

	* Required Field
I am a:	*
Dentist’s Name:	*
Dentist’s Specialty:
Address:

City:
County:
State:	*
Zip:
Phone Number:	*
	If patient or Agent/Broker; then
	If you are willing to allow us to use your name as a reference when we make contact with the provider, please enter your name below.
Your Name:
	If you would like to be updated once we have made contact with the provider, please enter your email address below.
Your email address:

IN 16346-1