DISCLOSURE FORM/CONTRACT ("CONTRACT")
This booklet is a Disclosure Form/Contract ("Contract") for your DeltaCare USA Individual/Family Dental Program ("Program") provided by:
Delta Dental Insurance Company
1000 Mansell Exchange West
Building 100, Suite 100
Alpharetta, Georgia 30022
This booklet discloses the terms and conditions of the Program available in Washington DC. PLEASE READ THE ENTIRE DOCUMENT COMPLETELY AND CAREFULLY. You have a right to review this Contract prior to enrollment.
THIS PROGRAM PROVIDES BENEFITS THROUGH CONTRACTING DENTISTS. PLEASE READ THE FOLLOWING INFORMATION SO THAT YOU WILL KNOW HOW TO OBTAIN DENTAL SERVICES. ADDITIONAL INFORMATION ABOUT YOUR BENEFITS IS AVAILABLE BY CALLING THE CUSTOMER SERVICE DEPARTMENT AT (800) 422-4234, 8 a.m. - 9 p.m., EASTERN TIME, MONDAY THROUGH RIDAY.
Right to Examine Disclosure Form/Contract
If you are not satisfied with the coverage as described in this Contract, you may request a full refund of the Premium and the one-time enrollment fee. This request must be made in writing within ten days from the date you receive this copy of the Contract. If you request this refund, no coverage will have been, or will be, provided. You will be responsible for any services obtained. |
