400N Enrollment Form - Dental Alternatives Insurance Services Inc

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Choice of Provider When you enroll in the SafeGuard plan, you and each enrolled family member must choose a Selected General Dental Office from our SafeGuard network. Each family member may select a different dental office. Please refer to the Directory of Participating Dentists for a complete listing of Selected General Dental Offices. Or you may access our website at www.safeguard.net to view SafeGuard General Dentists in your home or work zip codes. Facilities A complete list of contracted facilities is contained in the Directory of Participating Dentists. New Patient and Routine Services As a SafeGuard member, you have the right to expect that the first available appointment time for new patient or routine dental care services is within four (4) weeks of your initial request. If your schedule requires that an appointment be scheduled on a specific date, day of the week, or time of day, the Selected General Dentist may need additional time to meet your special request. Making an Appointment Once your coverage begins, you may contact the Selected General Dental Office you selected at enrollment to schedule an appointment. SafeGuard Selected General Dental Offices are open in accordance with their individual practice needs. When scheduling an appointment, please identify yourself as a SafeGuard member. Your Selected General Dental Office will also need to know your chief dental concern and basic personal data. Arrive early for your first appointment to complete any paperwork. There is an office visit co-payment on some plans and also be aware that there is a charge for missing your appointment. Your first visit to your dentist will usually consist of x-rays and an examination only. By performing these procedures first, your dentist can establish your treatment plan according to your overall health needs. We recommend that you take this brochure with you on your appointment, along with the enclosed Schedule of Benefits. Remember, only dental services listed as covered benefits in the Schedule of Benefits and provided by a SafeGuard Dentist are covered. SG-INDIV-EOC 5 CA 12/07 8/08
SmileSaver Individual & Family Enrollment Application To ensure that you’re correctly enrolled in the plan(s) you have selected, make sure to fill the form out completely. We cannot guarantee access to care if information is missing. With these plans, care is provided by a network dentist ... make sure you include the facility number for the providers you’ve chosen. Broker #: General Agent #: Master General #: Last Name First Name MI Subscriber SS# - - Home Address Apt. # City State Zip Code Male/Female Date of Birth Home Telephone ( ) Work Telephone ( ) Ext. Plan Selected: Dental: SM400 SM600 Must be completed to enroll: Facility # - 1 st Choice Facility # - 2 nd Choice Dependent Information: Select up to 3 dentists, 3 orthodontists and 1 vision care provider per family Last Name First Name MI Sex Birthdate Facility # - 1 st Choice Facility # - 2 nd Choice Spouse Child #1 Child #2 Child #3 Child #4 Must be completed to enroll in plan(s) Step 1. Select a rate Step 2. Select a payment option Annual Rates: Annual by check made payable to SmileSaver (include with application) Dental SM400 SM600 Subscriber Only $ 192.96 $ 69.96 Subscriber + One $ 288.96 $ 114.96 Subscriber + Family $ 397.92 $ 141.00 Monthly by credit card Annual by credit card Please charge my: VISA MasterCard Discover American Express Credit Card Number Expiration Date CID # One-time application fee (non-refundable) +$16.00 Name as it appears on credit card: _____ / ____ ______ Total Amount $ __________ I hereby authorize credit card payment in the amount indicated on this application: Monthly Rates: Signature: Date: Dental SM400 SM600 Subscriber Only $ 17.00 $ 6.65 Subscriber + One $ 25.20 $ 10.40 Subscriber + Family $ 34.50 $ 13.00 One-time application fee (non-refundable) +$16.00 Total Amount $__________ Monthly by checking account (Include check for first month’s payment. This is the account number we will use for your monthly bank debit.) Automatic Bank Account payments are deducted on or about the 20th of each month. I hereby authorize SafeGuard Health Plans, Inc., to debit the designated prepayment fee each month from my bank account. This authorization will remain in effect until I notify SafeGuard, in writing, 30 days prior to termination. My bank is authorized to make any necessary corrections. Signature: Date: Use and Disclosure of Personal Health Information: Agreement - I understand that any dispute or controversy which may arise between SafeGuard Health Plans, Inc., a California Corporation and myself, may be submitted to binding arbitration in lieu of a jury or court trial. Authorization to release dental/vision records - I hereby authorize the release and disclosure to review, or to obtain a copy of, any and all dental records which pertain to me or any member of my family, maintained by my chosen selected provider and/or specialist, to SafeGuard and/or any designated agent or representative for the purposes of dental treatment, care and for SafeGuard’s quality assessment and utilization reviews, which will be kept strictly confidential. This authorization shall remain valid for the term of this coverage. I understand that the initial term of the plan contract is for one year. Signature: Date: Mail this application to: SmileSaver - DAIS 3720 S. Susan St. #200 Santa Ana, CA 92704 Visit SafeGuard’s website at www.safeguard.net for current provider listings SmileSaver sm Dental & Vision products are provided by SafeGuard Health Plans, Inc. SM-IND-FAM-EF 4/07
Page 1 and 2: Dental HMO SmileSaver Individual 40
Page 3 and 4: SmileSaver dental and vision plans
Page 5 and 6: DIRECT REFERRAL DENTAL PLAN* Diagno
Page 7 and 8: Code Crowns • Cost of Noble or Hi
Page 9 and 10: Code D5211 D5212 D5213 D5214 D5225
Page 11 and 12: Code D7250 D7510 D7530 D7550 D7910
Page 13 and 14: Dental Terminology Definitions Thes
Page 15 and 16: Principle Exclusions and Limitation
Page 17 and 18: Principle Exclusions and Limitation
Page 19 and 20: Evidence of Coverage and Disclosure
Page 21: Who May Enroll You may enroll yours
Page 25 and 26: Uniform Health Plan Benefits and Co
Page 27 and 28: No co-payment is required for a sec
Page 29 and 30: prescribed time, the member must ma
Page 31 and 32: • Failure to establish a satisfac
Page 33 and 34: TDD number for the hearing impaired
Page 35 and 36: The following definitions are used
Page 37 and 38: SAFEGUARD DENTAL & VISION HIPAA NOT
Page 39 and 40: Information to a coroner or medical
Page 41 and 42: electronically). The first list you
Page 44 and 45: 000685723/3297-CA-DAIS-CDT9KIT-1
Page 46: SM-DHMO-C

400N Enrollment Form - Dental Alternatives Insurance Services Inc

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