|
|
 |
|
| 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 of New York, Inc.
575 Madison Avenue
New York, New York 10022
This booklet describes the terms and conditions of the Program available in New York. 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.
The Contract Term is one year. Coverage will renew automatically at the end of each Contract Term as long as the annual premium is paid before the end of the 30 day grace period. Refer to Renewal, Cancellation and Termination of Benefits and Grace Period.
Dependent children are eligible up to the age of 19, or if they are full-time students, up to age 23.
Refer to Who is Eligible for Coverage for additional information.
Right to Examine Disclosure Form/Contract
New York Insurance Law requires that you have an opportunity to request a full refund of the Premium and the one-time enrollment fee 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.
|
|
|
|
HIPAA Notice of Privacy Practices | Web Site Privacy Notice
© 2011 Delta Dental |
|
