Dental Practitioners Program Registration

Dental Practitioners Program Registration
Select Coverage
Our plans start on the 1st of each month, please indicate your requested start date

MonthDayYear
Date
Primary Account Holder
Name

First NameLast Name
Email
example@example.com
Occupation
Years in Industry
Account Holder Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Account Holder Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Account Holder Birthdate

MonthDayYear
Date
Account Holder Gender

Other
- My Partner already has coverage through another provider
- My Partner has provincial health care coverage
- If yes, please provide carrier and policy number
- Partner Name
  
  First NameLast Name
- Partner Birthdate
  
  MonthDayYear
  Date
- Partner Gender
  
  Other
- Dependant #1 Name
  
  First NameLast Name
- Dependant #1 Birthdate
  
  MonthDayYear
  Date
- Dependant #1 Gender
  
  Other
- Dependent #1 has provincial health care coverage
- Dependant #2 Name
  
  First NameLast Name
- Dependant #2 Birthdate
  
  MonthDayYear
  Date
- Dependant #2 Gender
  
  Other
- Dependent #2 has provincial health care coverage
- Dependant #3 Name
  
  First NameLast Name
- Dependant #3 Birthdate
  
  MonthDayYear
  Date
- Dependant #3 Gender
  
  Other
- Dependent #3 has provincial health care coverage
- Additional Dependants (Full Name, DOB, Gender and if they have provincial health care coverage)
- Legal Company Name
- Company Address, if different than home address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- A HCSA requires that the dollar allocation be determined at the start of the yearly term, once this is set the amount cannot be changed until the plans annual renewal. For example if you select to have $3000 allocated for your HCSA for a plan that starts on July 1st, 2024, you cannot change that amount until you renew that plan again on July 1st, 2025; one full calendar year later. Any costs outside of the predetermined $3000 would be out of pocket and not covered under your HCSA.
- Add a HCSA to my plan (for extra cost)
- Yearly Dollar Allocation for Health Care Spending Account
- Bloom Benefits Group is committed to protecting and respecting your privacy, and we’ll only use your personal information to administer your account and to provide the products and services you requested from us. From time to time, we would like to contact you about our products and services, as well as other content that may be of interest to you. If you consent to us contacting you for this purpose, please tick below to say how you would like us to contact you:
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Dental Practitioners Program Registration

Primary Account Holder