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DENTAL by linzhengnd


									                  Plan Exclusions
                                                            D E N TA L
The following services are not available for a discount
through this plan: Services provided by a dentist;
other than a Willamette Dental Group, P.C., provider.
Services received before the effective date, before
cancellation for a full refund; or after the termination        OREGON
date of membership. General anesthetic, IV sedation
or hospitalization charges. Dental treatment not
performed in a Willamette Dental Office Group, P.C.
office. Cosmetic dentistry. Dental treatment which your
Willamette Dental Group, P.C. provider determines to be
unnecessary or harmful to the member. Charges by any
person other than a licensed dentist, licensed denturist,
or licensed hygienist. This plan does not coordinate
benefits. Willamette Dental Insurance, Inc. may refuse to
renew your membership for reasons permitted by law.

Please refer to your Policy for a complete description of
exclusions and limitations.

             Dental Plus of Oregon
           Customer Service Number
          Outside Portland Call Toll Free

                                                            This discount dental plan is provided by
                                                               Willamette Dental Insurance, Inc.
                           plus Oregon
                                                                 Dental Offices
                                                                 With more than 50 dental office locations
                                                                 throughout Idaho, Washington, Oregon, there
                                                                 is probably a Willamette Dental Office near your
                                                                 work or home.

                                                                 Oregon Locations
                                                                 Portland Metro         Central Oregon
                                                                 Beaverton              Bend
                                                                                        Oregon Coast
                                                                                        Lincoln City
                                                                 Milwaukie              Southwest Washington
      Affordable                                                 Stark Street
                                                                 Tigard - Scholls
                                                                                        Hazel Dell
            Quality                                              Tualatin
                                                                 Weilder Street
                                                                                        Mill Plain
    Dental Care for You                                          Salem                  Specialty Offices
      & Your Family                                              Liberty
                                                                                        Beaverton Specialty
                                                                                        Gateway Specialty
         • No Waiting Periods                                    Southern Oregon        Stark Specialty
         • Emergency Dental Care                                 Corvallis
                                                                 Grants Pass
         • Orthodontia for All Ages                              Eugene
With Willamette Dental Group, P.C. you are assured quality       Springfield
dental care. Each of our clinical professionals meets and
maintains one of the highest credentialing standards in
the dental industry. Providers practice an evidence-based
approach to dentistry, which simply means that each patient            To Find A Dental Office Near You
receives the most appropriate care for their individual needs.

Dental Plus is not insurance. Plan Members                    Dental Plus entitles you to a 25%
must pay for all dental and ancillary services,               discount in fees from Willamette
but will receive a discount from providers.                   Dental Group, P.C. for:
Willamette Dental Insurance, Inc. is pleased to offer you
Dental Plus, a cost saving dental plan. This plan gives you           •	General	examinations
simple access to quality dental care at a reduced fee.        	       •	Cleanings
Orthodontia is available for both adults and children.
                                                              	       •	Restorations	(fillings)
When utilizing this plan you will never need to fill out or   	       •	Crowns
submit any claim forms. As a plan member, you simply          	       •	Dentures	or	partial	dentures
schedule your appointments, see the dentist and pay at
that visit. Dental Plus makes access to quality dental care
easy and affordable.

To participate in the Dental Plus Plan you must be a
resident of Oregon and you must receive your care at a        Dental Plus entitles you to a 15%
Willamette Dental Group P.C. location. With more than
50 dental offices throughout Oregon, Washington and           discount in fees from Willamette
Idaho, there is likely a location convenient to you. For      Dental Group, P.C. for:
locations and directions please visit us on the web at                                             •	Orthodontia
Advance appointments are required. To schedule your           	       •	Oral	surgery
dental or emergency care appointment please call              	       •	Pediatrics (dentistry for children)
503-952-2100 in the Portland Metro Area or toll free          	       •	Periodontics (gum & bone problems)
at 800-461-8994.                                              	       •	Endodontics	(root canals)
When you speak to a Willamette Dental representative          	       •	Denturist	services
or arrive at a dental office for your appointment, simply
identify yourself as a Dental Plus member. You will then
receive quality dental care at a discount.

Most offices are open Monday through Friday and
occasionally Saturdays, 7 AM to 6 PM. In making your
appointments you can anticipate being seen within the
following time-lines:
    •	 Emergencies: Within Approximately 24 Hours
    •	 First Appointment (New Patients): 30 Days
    •	 Regular Hygiene (Cleanings): 45 Days
    •	 Operative (Restorative Treatment): 60 Days                     Willamette Dental Insurance, Inc.
                                                                  6950 NE Campus Way, Hillsboro, OR 97124
With the exception of emergencies, the number of days
are averages. The length of wait-time may vary based on
your choice of dentist, location, and preferred day or time
of appointment.
One Year Membership Fees*

Single Membership $78.00
Double Membership $156.00
Family Membership $198.00

Payment can be by credit card, check or money order.
The Company reserves the right to change the fees or
provisions of the Membership Agreement. Dental Plus
Membership must be renewed annually to continue your
membership. Make checks payable & mail to:
               Willamette Dental Insurance, Inc.
               Dental Plus
               6950 NE Campus Way
               Hillsboro, OR 97124

For Credit Card Payment, please complete the following:
   o Visa         o MasterCard    o Discover Card
Credit card number:
CSC (3 digit card security code):
Expiration date:
Signature:                                                     How to Enroll
Date:                                                          To enroll in Dental Plus, simply complete the application
                                                               form and submit it along with payment. No physical
Agreement                                                      examinations are required for enrollment and there is
                                                               no waiting period for access to dental services once you
I hereby apply for membership in the discount dental plan,     are a member. Membership fees must be received by
Dental Plus, offered through Willamette Dental Insurance,      the 25th of the month preceding the renewal date or
Inc. (hereafter “the Company”) for myself and all listed       effective date for membership to be active.
dependents. To the best of my knowledge, the information
that I have provided in this application form is true and      Family memberships may include a legal spouse or
complete. If this request for membership is acceptable to      domestic partner and unmarried dependent children
the Company under its current rules and practices and it is    from birth through age 18 and through age 23 if a
legally permissible, a Dental Plus Membership Agreement        registered student in full-time attendance at an accredited
will be issued. If enrolled by the 25th of the month the       educational institution. Dependent children are not
effective date will be the first day of the following month.   eligible for single membership. Dental Plus must
I agree to pay in advance the appropriate membership           be renewed annually to continue membership. If
fees for myself and all listed dependents and authorize        enrolled by the 25th of the month the effective date
membership fees increases as the Company deems                 will be the first day of the following month.
necessary. I understand that payment of membership fees
is acceptance of the terms of Membership Agreement. I          In order to receive discounted dental services, charges must
agree to advise the Company of any change in status within     be paid in full at the time of the visit. Please check with
60 days from the date of change.                               your Willamette Dental Group, P.C., provider for charges
                                                               on specific treatment. Visa, MasterCard and Discover are
Applicant’s signature:                                         accepted. Membership in Dental Plus must be continuous
Date:                                                          over the treatment period to receive discounted services.

                                                               If you wish additional information please call
                                                               503-952-2711 or visit us on the web at:
*Membership fees are subject to change.              
Willamette Dental Insurance, Inc.                                                                                      D E N TA L

Dental Plus Application Form
Please	print	or	type	•	Shaded	areas	are	for	producer	or	office	use	only	         	        	        Account	Number:

Name of Subscriber: Last, First, Middle Initial

Address:                                                                 City:                     State:    OR        Zip:

Home Phone:                                                              Social Security Number:

Date of Birth:                                                           M/F:

Effective Date:                                                          Renewal Date:

Membership (check one):               o Single    o Double    o Family
                                                       List All Persons Below That You Wish to Enroll

Spouse or Domestic Partner's Name:                                       Date of Birth:                                       M/F:
(Full Name)                                                              Social Security Number:

Dependent Name:                                                          Date of Birth:                                       M/F:
(Full Name & Relationship)                                               Social Security Number:

Dependent Name:                                                          Date of Birth:                                       M/F:
(Full Name & Relationship)                                               Social Security Number:

Dependent Name:                                                          Date of Birth:                                       M/F:
(Full Name & Relationship)                                               Social Security Number:

                                          Total Number of Family Members                      $             Enclosed

 o New Patient                                                                                     Pay Commissions To:
 o Existing Patient                                                                                               Agent                Agency
 Agent or Agency Name:                                                                             Agent SSN or Agency Tax ID

 Agent or Agency Address:

 Agent or Agency State License Number:                                                             Phone:

Agreement Form No. 2121 - OR (6/09)

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