Is this the correct address?
[MM_Member_Decision isMember="false"]
Join Now And Start Saving Right Away
If you’re a TX Dental Plan affiliate provider enrolling your patient(s) on TX Dental Plan, simply fill out the member(s) account information, billing and payment information, then input your unique provider ID number.
We have emailed you a confirmation letter and payment receipt.
If you don't see them in your inbox, please check your
[MM_Form type='checkout']
[MM_Form_Message type='error']
Account
Billing
Payment
Confirmation
[MM_Order_Decision membershipId='2']
[/MM_Order_Decision][MM_Order_Decision membershipId='3']
[/MM_Order_Decision][MM_Order_Decision membershipId='4']
[/MM_Order_Decision]
Good Choice!
[MM_Order_Decision membershipId='2']
[/MM_Order_Decision]
[MM_Order_Decision membershipId='3']
[/MM_Order_Decision]
[MM_Order_Decision membershipId='4']
[/MM_Order_Decision]
Savings Start Immediately
NO waiting periods
NO maximums
NO exclusions
NO hassles
[MM_Form_Section type="accountInfo"]
[MM_Order_Decision membershipId='2']
Account Information
First Name: [MM_Form_Field type="input" name="firstName" tabindex="-1" class="required errorr" customAttributes='placeholder="First Name"']
Last Name: [MM_Form_Field type="input" name="lastName" tabindex="-1" class="required errorr" customAttributes='placeholder="Last Name"']
Phone: [MM_Form_Field type='input' name='phone' customAttributes='placeholder="Phone Number"' class="required errorr"]
Email: [MM_Form_Field type="input" name="email" tabindex="-1" class="required errorr newpeep" customAttributes='placeholder="example@email.com"']
Password: [MM_Form_Field type="input" name="password" tabindex="-1" class="required errorr" customAttributes='placeholder="Password"']
Date of Birth:
[MM_Form_Field type='custom' id='1' isRequired='true' class='dob']
[MM_Form_Field type='custom' id='2' isRequired='true' class='dob']
[MM_Form_Field type='custom' id='3' isRequired='true' class='dob']
How many are in your family?
[MM_Form_Field type='custom' id='4' isRequired='false' class='familyselector' tabindex="-1"]
[/MM_Order_Decision]
[MM_Order_Decision membershipId='3']
Account Information
First Name: [MM_Form_Field type="input" name="firstName" tabindex="1" class="required errorr" customAttributes='placeholder="First Name"']
Last Name: [MM_Form_Field type="input" name="lastName" tabindex="3" class="required errorr" customAttributes='placeholder="Last Name"']
Phone: [MM_Form_Field type='input' name='phone' customAttributes='placeholder="Phone Number"' class="required errorr"]
Email: [MM_Form_Field type="input" name="email" tabindex="-1" class="required errorr newpeep" customAttributes='placeholder="example@email.com"']
Password: [MM_Form_Field type="input" name="password" tabindex="-1" class="required errorr" customAttributes='placeholder="Password"']
Date of Birth:
[MM_Form_Field type='custom' id='1' isRequired='true' class='dob']
[MM_Form_Field type='custom' id='2' isRequired='true' class='dob']
[MM_Form_Field type='custom' id='3' isRequired='true' class='dob']
How many are in your family?
[MM_Form_Field type='custom' id='4' isRequired='false' class='familyselector' tabindex="-1"]
Account Information
Second Member
(2) First Name: [MM_Form_Field type='custom' id='8' isRequired='true' value="0" tabindex="-1" class="required errorr"]
(2) Last Name: [MM_Form_Field type='custom' id='9' isRequired='true' value="0" tabindex="-1" class="required errorr"]
[/MM_Order_Decision]
[MM_Order_Decision membershipId='4']
Account Information
First Name: [MM_Form_Field type="input" name="firstName" tabindex="-1" class="required errorr" customAttributes='placeholder="First Name"']
Last Name: [MM_Form_Field type="input" name="lastName" tabindex="-1" class="required errorr" customAttributes='placeholder="Last Name"']
Phone: [MM_Form_Field type='input' name='phone' customAttributes='placeholder="Phone Number"' class="required errorr"]
Email: [MM_Form_Field type="input" name="email" tabindex="-1" class="required errorr newpeep" customAttributes='placeholder="example@email.com"']
Password: [MM_Form_Field type="input" name="password" tabindex="-1" class="required errorr" customAttributes='placeholder="Password"']
Date of Birth:
[MM_Form_Field type='custom' id='1' isRequired='true' class='dob']
[MM_Form_Field type='custom' id='2' isRequired='true' class='dob']
[MM_Form_Field type='custom' id='3' isRequired='true' class='dob']
Account Information
How many are in your family?
[MM_Form_Field type='custom' id='4' isRequired='false' class='familyselector' tabindex="-1"]
Second Family Member
(2) First Name: [MM_Form_Field type='custom' id='8' isRequired='true' value="0" class="required errorr"]
(2) Last Name: [MM_Form_Field type='custom' id='9' isRequired='true' value="0" class="required errorr"]
Third Family Member
(3) First Name: [MM_Form_Field type='custom' id='10' isRequired='false' class="required errorr"]
(3) Last Name: [MM_Form_Field type='custom' id='11' isRequired='false' class="required errorr"]
Fourth Family Member
(4) First Name: [MM_Form_Field type='custom' id='12' isRequired='false' class="required errorr"]
(4) Last Name: [MM_Form_Field type='custom' id='13' isRequired='false' class="required errorr"]
Fifth Family Member
(5) First Name: [MM_Form_Field type='custom' id='14' isRequired='false' class="required errorr"]
(5) Last Name: [MM_Form_Field type='custom' id='15' isRequired='false' class="required errorr"]
Sixth Family Member
(6) First Name: [MM_Form_Field type='custom' id='16' isRequired='false' class="required errorr"]
(6) Last Name: [MM_Form_Field type='custom' id='17' isRequired='false' class="required errorr"]
Seventh Family Member
(7) First Name: [MM_Form_Field type='custom' id='18' isRequired='false' class="required errorr"]
(7) Last Name: [MM_Form_Field type='custom' id='19' isRequired='false' class="required errorr"]
Eighth Family Member
(8) First Name: [MM_Form_Field type='custom' id='20' isRequired='false' class="required errorr"]
(8) Last Name: [MM_Form_Field type='custom' id='21' isRequired='false' class="required errorr"]
Ninth Family Member
(9) First Name: [MM_Form_Field type='custom' id='22' isRequired='false' class="required errorr"]
(9) Last Name: [MM_Form_Field type='custom' id='23' isRequired='false' class="required errorr"]
Tenth Family Member
(10) First Name: [MM_Form_Field type='custom' id='24' isRequired='false' class="required errorr"]
(10) Last Name: [MM_Form_Field type='custom' id='25' isRequired='false' class="required errorr"]
[/MM_Order_Decision]
[/MM_Form_Section]
back: Account Information
[MM_Form_Section type='shippingInfo']
Shipping Address
Address: [MM_Form_Field name='shippingAddress' customAttributes='placeholder="Shipping Address"' class="required errorr"]
City: [MM_Form_Field name='shippingCity' customAttributes='placeholder="Shipping City"' class="required errorr"]
State: [MM_Form_Field name='shippingState' customAttributes='placeholder="Shipping State"' class="required"]
Zip: [MM_Form_Field name='shippingZipCode' customAttributes='placeholder="Shipping Zip Code"' class="required errorr"]
Country: [MM_Form_Field name='shippingCountry']
[/MM_Form_Section]
[MM_Form_Section type="billingInfo"]
Billing Address
[MM_Form_Field name='shippingSameAsBilling']Billing is same as Shipping
Address: [MM_Form_Field name='billingAddress' customAttributes='placeholder="Billing Address"' tabindex="-1" class="required errorr"]
City: [MM_Form_Field name='billingCity' customAttributes='placeholder="Billing City"' tabindex="-1" class="required errorr"]
State: [MM_Form_Field name='billingState' customAttributes='placeholder="Billing State"' tabindex="-1" class="required"]
Zip: [MM_Form_Field name='billingZipCode' customAttributes='placeholder="Billing Zip Code"' tabindex="-1" class="required errorr"]
Country: [MM_Form_Field name='billingCountry' tabindex="-1"]
[/MM_Form_Section]
Back: Billing Information
[MM_Form_Section type='billingInfo']
Payment Details
Credit Card: [MM_Form_Field name='ccNumber' customAttributes='placeholder="Credit Card Number"' class="required errorr"]
Security Code: [MM_Form_Field name='ccSecurityCode' customAttributes='placeholder="Security Code"' class="required errorr"]
Expiration Date: [MM_Form_Field name='ccExpirationDate']
*If paying by check or money order, please submit completed enrollment application along with payment via mail.
Enrollment Application
[/MM_Form_Section]
[MM_Form_Section type='coupon']
(optional)
[MM_Form_Field name='couponCode']
Apply ID
[MM_Form_Field type='custom-hidden' id='5' isRequired='false' class='']
[MM_Form_Message type='couponSuccess']
[MM_Form_Message type='couponError']
Affiliated Providers :
While facilitating enrollment, please inform your new member(s) that:
Welcome email and payment receipt will be sent to their email.
Membership kit, including Welcome Letter, copy of Member Terms & Conditions, and Plan ID cards will arrive at their address in 7-10 business days.
[/MM_Form_Section]
Back: Payment Information startover
Order Details
[MM_Order_Decision membershipId='2']
Product Price: $76.00
[/MM_Order_Decision]
[MM_Order_Decision membershipId='3']
Product Price: $96.00
[/MM_Order_Decision]
[MM_Order_Decision membershipId='4']
Product Price: $116.00
[/MM_Order_Decision]
[MM_Order_Decision isDiscounted='true']
Discount: [MM_Form_Data name='discount']
[/MM_Order_Decision]
Total Price: [MM_Form_Data name='totalPrice'] per year
Savings Start Immediately
NO waiting periods
NO maximums
NO exclusions
NO hassles
[/MM_Form]
[/MM_Member_Decision]
[MM_Member_Decision isMember="true"]
[MM_Form type='checkout']
[MM_Form_Message type='error']
[MM_Order_Decision membershipId='2']
Transaction Error
There was an error while processing your transaction.
If you need help please don't hesitate to call our Member Engagement Specialists at
(888) 644-5401 .
[/MM_Order_Decision]
[MM_Order_Decision membershipId='3']
Product Price: $96.00
[MM_Form_Section type="accountInfo"]
First Name: [MM_Form_Field type="input" name="firstName"]
Last Name: [MM_Form_Field type="input" name="lastName"]
Email: [MM_Form_Field type="input" name="email"]
Password: [MM_Form_Field type="input" name="password"]
Phone: [MM_Form_Field type="input" name="phone"]
[/MM_Form_Section]
How many are in your family?
[MM_Form_Field type='custom' id='4' isRequired='false' class='familyselector' tabindex="-1"]
Upgrade Information
Second Member
(2) First Name: [MM_Form_Field type='custom' id='8' isRequired='true' value="0" tabindex="-1" class="required errorr"]
(2) Last Name: [MM_Form_Field type='custom' id='9' isRequired='true' value="0" tabindex="-1" class="required errorr"]
[MM_Form_Section type='billingInfo']
New Billing Info
Address: [MM_Form_Field name="billingAddress"]
City: [MM_Form_Field name="billingCity"]
State: [MM_Form_Field name="billingState"]
Zip Code: [MM_Form_Field name="billingZipCode"]
Country: [MM_Form_Field name="billingCountry"]
Credit Card: [MM_Form_Field name='ccNumber' customAttributes='placeholder="Credit Card Number"' class="required errorr"]
Security Code: [MM_Form_Field name='ccSecurityCode' customAttributes='placeholder="Security Code"' class="required errorr"]
Expiration Date: [MM_Form_Field name='ccExpirationDate']
[/MM_Form_Section]
Order Confirmation
Total: [MM_Form_Data name='totalPrice']
per year
[MM_Form_Field type='custom' id='6' isRequired='true' class='readtandc']
Patient has read the Terms and Conditions
[/MM_Order_Decision]
[MM_Order_Decision membershipId='4']
Product Price: $116.00
[MM_Form_Section type="accountInfo"]
First Name: [MM_Form_Field type="input" name="firstName"]
Last Name: [MM_Form_Field type="input" name="lastName"]
Email: [MM_Form_Field type="input" name="email"]
Password: [MM_Form_Field type="input" name="password"]
Phone: [MM_Form_Field type="input" name="phone"]
[/MM_Form_Section]
Upgrade Information
How many are in your family?
[MM_Form_Field type='custom' id='4' isRequired='false' class='familyselector' tabindex="-1"]
(2) First Name: [MM_Form_Field type='custom' id='8' isRequired='true' value="0" class="required errorr"]
(2) Last Name: [MM_Form_Field type='custom' id='9' isRequired='true' value="0" class="required errorr"]
(3) First Name: [MM_Form_Field type='custom' id='10' isRequired='false' class="required errorr"]
(3) Last Name: [MM_Form_Field type='custom' id='11' isRequired='false' class="required errorr"]
(4) First Name: [MM_Form_Field type='custom' id='12' isRequired='false' class="required errorr"]
(4) Last Name: [MM_Form_Field type='custom' id='13' isRequired='false' class="required errorr"]
(5) First Name: [MM_Form_Field type='custom' id='14' isRequired='false' class="required errorr"]
(5) Last Name: [MM_Form_Field type='custom' id='15' isRequired='false' class="required errorr"]
(6) First Name: [MM_Form_Field type='custom' id='16' isRequired='false' class="required errorr"]
(6) Last Name: [MM_Form_Field type='custom' id='17' isRequired='false' class="required errorr"]
(7) First Name: [MM_Form_Field type='custom' id='18' isRequired='false' class="required errorr"]
(7) Last Name: [MM_Form_Field type='custom' id='19' isRequired='false' class="required errorr"]
(8) First Name: [MM_Form_Field type='custom' id='20' isRequired='false' class="required errorr"]
(8) Last Name: [MM_Form_Field type='custom' id='21' isRequired='false' class="required errorr"]
(9) First Name: [MM_Form_Field type='custom' id='22' isRequired='false' class="required errorr"]
(9) Last Name: [MM_Form_Field type='custom' id='23' isRequired='false' class="required errorr"]
(10) First Name: [MM_Form_Field type='custom' id='24' isRequired='false' class="required errorr"]
(10) Last Name: [MM_Form_Field type='custom' id='25' isRequired='false' class="required errorr"]
[MM_Form_Section type='billingInfo']
New Billing Info
Address: [MM_Form_Field name="billingAddress"]
City: [MM_Form_Field name="billingCity"]
State: [MM_Form_Field name="billingState"]
Zip Code: [MM_Form_Field name="billingZipCode"]
Country: [MM_Form_Field name="billingCountry"]
Credit Card: [MM_Form_Field name='ccNumber' customAttributes='placeholder="Credit Card Number"' class="required errorr"]
Security Code: [MM_Form_Field name='ccSecurityCode' customAttributes='placeholder="Security Code"' class="required errorr"]
Expiration Date: [MM_Form_Field name='ccExpirationDate']
[/MM_Form_Section]
Order Confirmation
Total: [MM_Form_Data name='totalPrice']
per year
[MM_Form_Field type='custom' id='6' isRequired='true' class='readtandc']
Patient has read the Terms and Conditions
[/MM_Order_Decision]
[/MM_Form]
[/MM_Member_Decision]