DeltaCare USA Individual/Family Dental HMO Program: My Costs




	How much do I pay? What are my payment choices? Mailing instructions Copayments and other charges

MAILING INSTRUCTIONS

Please mail the completed Enrollment and Payment Authorization Form with either credit card information or a check or money order for the Premium and the $15.00 enrollment fee to: Delta Dental of California Dept. 0170 Los Angeles, CA 90084-0170


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