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| DISCLOSURE FORM / CONTRACT ("CONTRACT") |
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This booklet is a Disclosure Form/Contract ("Contract") for your DeltaCare USA Senior Dental Program ("Program") provided by:
Delta Dental Insurance Company
1000 Mansell Exchange West
Building 100, Suite 100
Alpharetta, GA 30022
(800) 422-4234
This booklet discloses the terms and conditions of the Program available in Florida. PLEASE READ THE ENTIRE DOCUMENT COMPLETELY AND CAREFULLY. You have a right to review this Contract prior to enrollment.
PLEASE READ THE FOLLOWING INFORMATION SO THAT YOU WILL KNOW HOW TO OBTAIN DENTAL SERVICES. YOU MUST OBTAIN DENTAL BENEFITS FROM (OR BE REFERRED FOR SPECIALIST SERVICES BY) YOUR ASSIGNED CONTRACT DENTIST.
Benefits for preexisting conditions (e.g. missing teeth) are covered under the DeltaCare USA Program. However, Benefits are not provided for dental treatment in progress at inception of eligibility in this Program. Refer to Exclusion of Benefits #18.
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 FRIDAY.
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