Dental HMO/Managed Care Network

Please complete the below form to request an application for participation in the Dental HMO/Managed Care Network in the states of California, Florida, Texas and New Jersey, and select counties in the states of New York, Pennsylvania and Connecticut.

Practice Information (where services are rendered)

*Required Fields

*Practice Name:

*Practice Address:

Practice Address 2:

*Practice City:

*Practice State:

*Practice Zip:

*Practice Phone:

*Practice Email:

*Is this Facility/Dental Practice currently participating in the
MetLife HMO/Managed Care Network?

Yes No

*Is this Facility/Dental Practice currently participating in the
MetLife PPO Network?

Yes No

Dentist's Information

*Required Fields

*First Name:

*Last Name:

*Email:

*Is this dentist currently participating in the
MetLife PPO Network?

Yes No

Each individual dentist, within a dental facility, that is interested in participating in the Dental HMO/Managed Care Network must complete a PROVIDER CONTRACT APPLICATION. In addition, each individual dental facility must complete a FACILITY CONTRACT APPLICATION.

*Please select one (1) provider specialty from the drop down:

Please be sure all fields have been completed and select Submit.