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FIND A FORM

Find the Forms You Need Fast.

We know you're busy, so we've made the forms you need easily accessible.  Please click on the pdf link and download your forms. 

Administrative

ADA Claim Form (pdf)Download
Protected Health Information Release Authorization (pdf)Download
SecureCare Employer Master Group Application (pdf)Download
SecureCare Enrollment Form - Dental Vision (pdf)Download
SecureCare Enrollment Form - Dental Vision Life (pdf)Download
SecureCare Enrollment Form - Dental Vision STDI (pdf)Download
SecureCare Enrollment Form - Dental Vision Life STDI Accident (pdf)Download

Arizona Dental Benefits

AZ100 Schedule of Copays ENGLISH (pdf)Download
AZ100 Schedule of Copays SPANISH (pdf)Download
AZ300 Schedule of Copays ENGLISH (pdf)Download
AZ300 Schedule of Copays SPANISH (pdf)Download
AZ400 Schedule of Copays ENGLISH (pdf)Download
AZ400 Schedule of Copays SPANISH (pdf)Download
AZ500 Schedule of Copays ENGLISH (pdf)Download
AZ500 Schedule of Copays SPANISH (pdf)Download
SecureCare Dental Covered Codes (pdf)Download

Nevada Dental Benefits

NV Non Network Benefits Payments ENGLISH (pdf)Download
NV Non Network Benefits Payments SPANISH (pdf)Download
NV100 Schedule of Copays ENGLISH (pdf)Download
NV100 Schedule of Copays SPANISH (pdf)Download
NV300 Schedule of Copays ENGLISH (pdf)Download
NV300 Schedule of Copays SPANISH (pdf)Download
NV400 Schedule of Copays ENGLISH (pdf)Download
NV400 Schedule of Copays SPANISH (pdf)Download
NV500 Schedule of Copays ENGLISH (pdf)Download
NV500 Schedule of Copays SPANISH (pdf)Download
SecureCare Dental Covered Codes (pdf)Download

Vision Plan Benefits

Davis Vision & EPIC Hearing Brochure (pdf)Download
SecureCare Vision Plan Summary (pdf)Download
Vision Value Added Features - English (pdf)Download
Vision Value Added Features - Spanish (pdf)Download

Dental & Vision Certificate & Policy

Dental Certificate AZ (pdf)Download
Dental Certificate NV (pdf)Download
Dental Policy AZ (pdf)Download
Dental Policy NV (pdf)Download
Vision Certificate AZ (pdf)Download
Vision Certificate NV (pdf)Download
Vision Policy AZ (pdf)Download
Vision Policy NV (pdf)Download
HIPAA Notice of Privacy Practices (pdf)Download

Group Term Life Certificate, Policy & Riders

Group Term Life - AZ ADD&P Rider (pdf)Download
Group Term Life - AZ Certificate (pdf)Download
Group Term Life - AZ Policy (pdf)Download
Group Term Life - NV ADD&P Rider (pdf)Download
Group Term Life - NV Certificate (pdf)Download
Group Term Life - NV Policy (pdf)Download
Group Term Life - Terminal Illness Rider (pdf)Download
Group Term Life - Waiver of Premium Rider (pdf)Download
Group Voluntary Term Life AZ Certificate (pdf)Download
Group Voluntary Term Life AZ Policy (pdf)Download
Group Voluntary Term Life NV Certificate (pdf)Download
Group Voluntary Term LIfe NV Policy (pdf)Download
HIPAA Notice of Privacy Practices (pdf)Download

Short Term Disability Certificate, Policy & Riders

Short Term Disability - Accidental Death Benefit Rider (pdf)Download
Short Term Disability - Emergency Room Benefit Rider (pdf)Download
Short Term Disability - Hospital Admission Benefit Rider (pdf)Download
Short Term Disability - Outpatient Surgery Benefit Rider (pdf)Download
Short Term Disability - Rehabilitation Services Benefit Rider (pdf)Download
Short Term Disability - Term Life Insurance Benefit Rider (pdf)Download
Short Term Disability - Wellness and Preventive Care Benefit Rider (pdf)Download
Short Term Disability AZ Certificate (pdf)Download
Short Term Disability NV Certificate (pdf)Download
Short Term Disability NV Policy (pdf)Download
Short Term Disability AZ Policy (pdf)Download
HIPAA Notice of Privacy Practices (pdf)Download

Accident Certificate & Policy

Accident Certificate AZ (pdf)Download
Accident Certificate NV (pdf)Download
Accident Policy AZ (pdf)Download
Accident Policy NV (pdf)Download
HIPAA Notice of Privacy Practices (pdf)Download

Dentists

ADA Claim Form (pdf)Download
General Dentist Contract (pdf)Download
Associate Application (pdf)Download
Provider Schedule of Copays - AZ100 (pdf)Download
Provider Schedule of Copays - AZ300 (pdf)Download
Provider Schedule of Copays - AZ400 (pdf)Download
Provider Schedule of Copays - AZ500 (pdf)Download
Provider Schedule of Copays - NV100 (pdf)Download
Provider Schedule of Copays - NV300 (pdf)Download
Provider Schedule of Copays - NV400 (pdf)Download
Provider Schedule of Copays - NV500 (pdf)Download
SecureCare Dental Covered Codes (pdf)Download
Specialist Contract (pdf)Download

Brokers

SecureCare Dental Plan Provisions (pdf)Download

SecureOne Individual Plan

01 - Using your SecureOne Plan (pdf)Download
02 - SecureOne Dental Plan Summary (pdf)Download
03 - SecureOne Vision Plan Summary (pdf)Download
04 - SecureOne Hearing Plan Summary (pdf)Download
06 - SecureOne Chiropractic & Alternative Medicine (pdf)Download
07 - SecureOne Prescription Plan Summary (pdf)Download
08 - SecureOne Orthodontic Plan Services (pdf)Download
09 - SecureOne Individual Plan Summary (pdf)Download
10 - SecureOne Brochure (pdf)Download
11 - SecureOne Membership Fees (pdf)Download

Dental and Vision Insurance Underwritten by American National Life Insurance Company of Texas    Galveston, Texas.  

Life, Short Term Disability, Accident, Critical Illness, Cancer, Limited Medical and FlexCare Hospital & Medical Insurance Underwritten by Standard Life and Accident Insurance Company   Galveston, Texas. 

 
SecureOne Plan is not insurance and is, therefore, not underwritten by or associated with American National Life Insurance Company of Texas or Standard Life & Insurance Company, nor is it a part of the SecureCare Group Insurance plan. 


Copyright © 2021 SecureCare Group Insurance - All Rights Reserved.

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