Your Dental Benefits Through HealthCare.gov

Payment Form

We are glad you are here.

Thank you for choosing Dental Health Services through HealthCare.gov.

You can submit your payment information and dentist selection here. You can conveniently pay with either a credit card or your bank account information. Your first payment will not be withdrawn from your account until the beginning of your first month of coverage. Your payments will be withdrawn from your account between the 5th and the 15th of each month.

CLICK HERE TO SELECT A DENTIST

Member Information

Primary Subscriber Name

Birth Date (MM/DD/YYYY)

Address:

City:

State: Zip Code:

Phone:

Email:

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

( search )

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

Payment Information

Payment Frequency Payment Method

Card Type (Visa, MasterCard, or Discover) Cardholder Name

Card number

CVV Code

Expiration date

Bank Routing # Checking Account #

By selecting one of the above payment methods, you authorize Dental Health Services to withdraw the applicable premium from your account.

If you have questions about these terms, you are invited to speak with your Member Service Specialist at 800.63.SMILE