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Horizon centurion dental fee schedule 2021-2026

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The document is an enrollment application for the Horizon Centurion Dental Program, detailing the process for individuals and their dependents to enroll in dental coverage. It includes sections for personal information, payment options, eligibility criteria for dependents, and terms and limitations of the program. The program offers discounted dental services through participating providers and outlines responsibilities regarding payments and eligibility.

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Click ‘Get Form’ to open the Horizon Centurion Dental Fee Schedule 2021 in the editor.
Begin by entering your personal information in the designated fields, including your name, address, and contact numbers. Ensure accuracy for seamless communication.
In the 'Eligible Persons to be Enrolled' section, list yourself and any dependents. Fill out their names, dates of birth, sex, and social security numbers as required.
Calculate the total amount due based on your selection of individual or family coverage. Input this total in the appropriate field.
Choose your payment method by marking either 'Payment enclosed' or selecting a credit card option. Fill in all necessary details accurately.
Finally, review all entered information for completeness and accuracy before signing and dating the application at the bottom.

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