Are the traditional form of dental insurance. You
are free to choose your own dentist without penalty. The plan pays
all or part of the dentist's fee to the extent that it does not
exceed the Usual, Customary and reasonable fee( UCR) for that
service.
PPO's:
Are similar to indemnity plans in most ways, but
patients are offered financial incentives to select their dentist
from a list of dentists who have entered into an agreement with the
insurance company to accept a pre-set fee.
Dental HMO's:
Are not dental insurance at all. Under these
plans you must choose a participating dentist to receive benefits.
Discount Referral Plans:
Are plans are commonly "included" in
membership in some organization. The "insurance" pays
nothing to the provider at all. Typically, in return for having a
patient from the organization referred to his practice, the dentist
provides "free" examinations and gives some percentage
discount to the members.
Policyholder Name:
Contact Name:
City:
State:
ZIP Code:
Phone:
FAX:
E-mail Address:
Existing Carrier:
Current Plan:
Current Rate:
Effective Date:
/ /
Renewal Date:
/ /
Current Rates:
Single:
Husband/Wife:
Parent/Child:
Family:
Plan Design:
HMO
POS
In Network Only
In/Out Of Network
Contributions:
Employer Paid
Employee Paid
Employer and Employee Paid
Calendar Year Deductible:
$25
$50
Calendar Year Maximum:
$1000
$1500
Orthodontia Benefits:
Yes
No
For groups over 5 employees, please fax your census to
201-703-0045!!
