Guardian Members

Guardian PPO ADA Claim Form
HIPAA Authorization (English)
HIPAA Authorization (Spanish)

Member Grievance Forms

Guardian PPO
All States

Guardian DHMO
New York
Florida

Managed Dental Care
California

Managed DentalGuard
New Jersey
Texas

First Commonwealth
Illinois

Dependent Eligibility Certification Forms

Dependent Eligibility Certification Form – CO
Dependent Eligibility Certification Form – CT
Dependent Eligibility Certification Form – FL
Dependent Eligibility Certification Form – IL
Dependent Eligibility Certification Form – MA
Dependent Eligibility Certification Form – MN
Dependent Eligibility Certification Form – NY
Dependent Eligibility Certification Form – OH
Dependent Eligibility Certification Form – PA
Dependent Eligibility Certification Form – All other states – Student Certification

Premier/Access Members

Dentist Nomination Form
Dental Claim Form
HIPAA Authorization (English)
HIPAA Authorization (Spanish)
Notice of Privacy Practices (English)
Notice of Privacy Practices (Spanish)
Language Assistance Services
AZ Appeal Packet

Member Grievance Forms

Premier Grievance Form — PPO
Premier Grievance Form — DHMO (English)
Premier Grievance Form — DHMO (Spanish)
Premier Grievance Form — DHMO (Chinese)

Privacy Policies and Forms

Click here to view and download a complete list of Guardian privacy policies and forms.