400N Enrollment Form - Dental Alternatives Insurance Services Inc

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SM-DHMO-C
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 44 and 45: 000685723/3297-CA-DAIS-CDT9KIT-1

400N Enrollment Form - Dental Alternatives Insurance Services Inc

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