5afeGuard bental RM0 nrollment Form

1exas
our Name (Please Print) Late our 3ignature
30-0R0uP-Ll-1X
vlslt our webslte
at www.safeguard.net
for u-to-date rovlder
llstlngs.
Walver of Coverage
l have been given the opportunity to apply for group dental insuranoe, but:
Lo not ohoose to eleot this ooverage.
LPM0-Ll-1X 1/06
Authorlzatlon to release dental records - l hereby authorize the release and disolosure to review, or to obtain a oopy of, any and all dental reoords whioh
pertain to me or any member of my family, maintained by my ohosen 3eleoted 0eneral Lentist and/or 3peoialist, to 3afe0uard and/or any designated agent
or representative for the purposes of dental treatment, oare and for 3afe0uard's quality assessment and utilization reviews, whioh will be kept striokly
oonfidential. 1his authorization shall remain valid for the term of this ooverage.
Polnt of servlce otlon: 3afe0uard has arranged for indemnity insuranoe ooverage to be provided to eligible members for servioes not supplied by
3afe0uard. 1his arrangement is a benefit under the terms of this oontraot, and the Certifioate of lnsuranoe issued by 3afePealth Life lnsuranoe Company
whioh outlines the soope of ooverage and the manner in whioh the dental insuranoe ooverage may be used.
ln order to reoeive benefits from 3afe0uard Pealth Plans' Lental PM0 Plan, you must utilize only network providers, exoept for emergenoy dental oare, and
pay the oo-payments speoified in the Lvidenoe of Coverage. under the lndemnity polioy, you may utilize and provider but prior to reoeiving reimbursement,
your must meet the required deduotible and are responsible for the oo-insuranoe amount speoified in the polioy or oertifioate.
l ohoose to eleot the Point-of-3ervioe 0ption.
Prlmary language: Please note any communlcatlon lmalrment:
Please print olearly when oompleting the Lnrollment lorm and return it to your Benefits Coordinator. Choose a general dental offioe (faoility number) of your
ohoioe for eaoh eligible family member from the 3afe0uard Lireotory of Partioipating Lentists. lailure to do so may result in delays in reoeiving dental oare.
lf your first provider faoility seleotion is not available, 3afe0uard will prooess your seoond seleotion.
Beneflts Coordlnator Use 0nly
0roup/Lmployer Name Lffeotive Late Late of Pire 0roup No.
3ubsoriber 33#
Lxt. work 1elephone Pome 1elephone
Lip Code 3tate City
Apt. # Pome Address
Late of Birth
Ml lirst Name Last Name
Male/lemale
( ) ( )
5ubscrlber's lnformatlon
Faclllty Number - 2nd Cholce Faclllty Number - 1st Cholce
beendent lnformatlon
3pouse/
Child
Male/
lemale
Last Name lirst Name Ml
Late of
Birth
Faclllty Number
1st Cholce
Faclllty Number
2nd Cholce
Lisability
/N
3tudent
/N
- -
Must be comleted to enroll ln lan:
Must be comleted
to enroll ln lan
Faclllty numbers are found next to each General bentlst's name ln the 5afeGuard blrectory of Partlclatlng bentlsts and on our webslte at
www.safeguard.net.
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