Ameritas Life Insurance Corp. (Ameritas Group) continually recruits new dentists and specialists to join our dental network. If you are a member who has access to a dental network and your dentist is not an active network provider, you may request that an application packet be sent to their office for consideration of our program. Please complete the Provider Nomination Form in its entirety to ensure the appropriate information is sent to the office.
* = Required
It is helpful if we are able to share the name of the person who nominated the provider
to participate in our network. May we use your name when contacting this provider?