Harbor Dental Plan
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Membership Application

Available in Texas only.
Disponible en Tejas solamente.

Please fill out the form below for instant membership, or you can also download a membership application, fill it out and mail it back to us at Harbor Dental Plan, PO Box 1550, Bellaire, TX 77402-1550.

Si asistencia en español es necesaria, por favor llame al 1-800-284-0822 o oprima aquí para imprimir una forma de inscripción.

Oprima aquí para volver a la pagina en Español.

The Harbor Dental Plan is NOT health insurance.
The plan contains a 30 day satisfaction guarantee.
The plan provides discounts at certain health care providers for dental services. The plan does not make payments directly to the providers of dental services. The plan member is obligated to pay for all services rendered but will receive a discount from those providers who have contracted with Harbor Dental Plan, L.P. Discount Medical Plan Organization: Newbn Inc, 14240 Proton Rd, Dallas, TX 75244.

Membership Fee Options:

All monthly payment plans have a $9 annual processing fee.

Pay by month Pay annually
Member Only: $3.95 $47.40
Member plus one Dependent: $5.95 $71.40
Member plus two or more Dependents: $7.95 $95.40
Additional Cost for Vision, Pharmacy, Chiropractic: $3.95 $47.40

 
*Required Fields

*How Did You Hear About Us?When requested please enter referred by here:

*Plan Selection *Type of Membership
Dental Only
Member Only
Dental, Vision, Pharmacy & Chiropractic
Member + 1 Dependent
Member + 2 or more Dependents
Policy Holder/Primary Adult
*First Name: *Last Name:
*Social Security #: (555-55-5555)
*Birthdate: (mm/dd/yyyy)
*Address 1:
Address 2:
*City:
*State: *Zip: (12345 or 12345-1234)
*Home Phone:
Cell Phone:
Business Phone:
Email:
Provide materials in :
Additional Dependents
*Total Number of Additional Dependents:
1) First Name: Last Name:
Relationship:
Birthdate: (mm/dd/yyyy)
2) First Name: Last Name:
Relationship:
Birthdate: (mm/dd/yyyy)
3) First Name: Last Name:
Relationship:
Birthdate: (mm/dd/yyyy)
4) First Name: Last Name:
Relationship:
Birthdate: (mm/dd/yyyy)
5) First Name: Last Name:
Relationship:
Birthdate: (mm/dd/yyyy)
Payment
*Payment Terms: *Payment Method:
 
I understand that membership is on an annual basis only, and I agree to allow Harbor Dental Plan, LP to automatically debit my credit card on a monthly basis, as I have indicated above, until such time as my enrollment has been canceled.

By checking the box to the left I am confirming I have read and accept these conditions for membership. Do not check this box if you are part of an Employer Sponsored program.

EngEnr0505

 
Harbor Dental Plan   PO Box 1550 Bellaire, TX 77402-1551   Toll Free: 1-800-284-0822   Email: CustomerSupport@HarborDentalPlan.com
The Harbor Dental Plan is NOT health insurance. This discount card program contains a 30 day cancellation period. The plan provides discounts at certain health care providers for dental services. The plan does not make payments directly to the providers of dental services. The plan member is obligated to pay for all services rendered but will receive a discount from those providers who have contracted with Harbor Dental Plan, L.P. Discount Medical Plan Organization: Newbn Inc, 14240 Proton Rd, Dallas, TX 75244.
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