400N Enrollment Form - Dental Alternatives Insurance Services Inc

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000685723/3297-CA-DAIS-CDT9KIT-1
The Schedule of Benefits and the Exclusions and Limitations contained within this enrollment kit are provided to give you the details of your benefit plan. Also included is your Evidence of Coverage, which provides further information regarding plan benefits. Benefits provided by SafeGuard Health Plans, Inc. SafeGuard®is a registered trademark of SafeGuard Health Enterprises, Inc. SmileSaversm is a registered servicemark of SafeGuard Health Enterprises, Inc.
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 and 22: Who May Enroll You may enroll yours
Page 23 and 24: SmileSaver Individual & Family Enro
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 46: SM-DHMO-C

400N Enrollment Form - Dental Alternatives Insurance Services Inc

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