Your Dental Benefits Through
HealthCare.gov

Payment Form

We are glad you are here.

Thank you for choosing Dental Health Services through HealthCare.gov. To complete your enrollment, you must submit your binder payment. You can submit your personal and plan information here and set up your ongoing payment arrangements on the next page. When you click the "Submit" button at the bottom of the page, you will be taken to Instamed, our secure payment website.

It is important to enter the birthdates of all enrollees on the plan below the "Payment Information" section. This will ensure your card is charged the correct amount by Instamed.

Subscriber Information

First Name: Last Name:

Subscriber Number (optional):

Exchange Subscriber ID (optional):

Mailing Address:

City:

State: Zip Code:

Email:

Phone Number:

Your Selected Dentist Number:

Don't know which dentist to select yet? Not to worry! You can always log into your member portal and complete this step later

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* Please DO NOT include the state prefix to the dentist number. This should be a 2-4 digit number only.

Payment Information

Your Plan

Please select your payment frequency:

Effective Date:

Enrollee Birthdates
Please enter in all enrollees names and birthdates to calculate premium:

Your Premium

If you have questions, you are invited to speak with your Member Service Specialist at 855-495-0907. They are glad to help!

Your Dental Benefits Through HealthCare.gov