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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

Provider Information

* Provider Name: Specialty: Name of Practice:
* Street Address:
* City: * State: * Zip:
Phone Number: Fax Number:

Your Information

* Member Name:
* Street Address:
* City: * State: * Zip:
Phone Number: E-mail Address:
* Employer:

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? Yes      No

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Ameritas Group is a division of Ameritas Life Insurance Corp.