Alpha Provider Change Request - Beta Health Association

Please use the following form to request a change to your Alpha Dental Plan provider. This is only for current members of the Alpha (ADP) plan.

Current Member Provider Update Form:
New Provider Number: * Click to Select Provider (Please Note)

Member contact information (*required):
Member ID:
First Name:	*
Last Name:	*
Company/Group Name:
Address:	*
Address 2:
City:	*
State:	*
Zip Code:	*
Phone Number:	*
E-mail Address:	*
Please select a category that fits you best:
Can Beta Health Association, Inc. contact you via email? Yes
Did you find what you need? Please enter any details in the comments field below. Yes No
Comments:
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Colorado Alpha Plan Provider Change Request