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| DISCLOSURE FORM/CONTRACT |
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This booklet is a Disclosure Form/Contract ("Contract") for your DeltaCare USA Individual/Family Dental Program ("Program") provided by:
ALPHA Dental Programs, Inc.
700 Parker Square
Suite 150
Flower Mound, TX 75028
This booklet discloses the terms and conditions of the Program available in Maryland. 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 Friday.
Notice of Insured's Right to Examine Disclosure Form/Contract for Ten Days
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.
Provided by:
ALPHA Dental Programs, Inc.
1431 Greenway Drive
Suite 520
Irving, TX 75038
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