HOW TO USE THE DELTACARE USA PROGRAM/CHOICE OF CONTRACT DENTIST

When you enroll in the Program, you will select a Contract Dentist from the list of dental facilities included with this Disclosure Form/Contract. You must indicate the Contract Dentist's name and facility ID# on the Enrollment and Payment Authorization Form (attached to this Disclosure Form/Contract). YOU AND YOUR ELIGIBLE DEPENDENTS MAY OBTAIN TREATMENT FROM ANY CONTRACT DENTIST AT THE SAME FACILITY.

Shortly after enrollment, you will receive a DeltaCare USA membership packet which advises you of the Effective Date of your Program and the address and telephone number of your Contract Dentist. You may obtain covered dental services any time after the Effective Date stated in your membership packet. Simply call your Contract Dentist to make an appointment and identify yourself as an Enrollee in the DeltaCare USA Program. Your assigned Contract Dentist also maintains a 24-hour Emergency Services system seven days a week. Inquiries regarding availability of appointments and accessibility of Contract Dentists should be directed to the Customer Service department at (800) 422-4234.

EACH ENROLLEE MUST GO TO THE ASSIGNED CONTRACT DENTIST TO OBTAIN COVERED SERVICES EXCEPT FOR SPECIALIST SERVICES AUTHORIZED IN WRITING BY DELTA DENTAL OR FOR EMERGENCY SERVICES.

TREATMENT PROVIDED BY AN OUT-OF-NETWORK DENTIST IS NOT COVERED UNDER THIS PROGRAM UNLESS PREAUTHORIZED BY US.