Take care of your teeth with Federal Dental. Federal Dental Triple Option Dental Plan 202 Dental disease is preventable. Our plans encourage the early detection of dental problems and routine maintenance. We help you take better care of your teeth and now it can cost you less to do it. We give you the choice of three different dental options - choose the one that s right for you and your family. Dominion Dental Services (Dominion) is a leading administrator of dental and vision benefits in the Mid-Atlantic. Among our 470,000 customers are leading health plans, employer groups, municipalities, associations and individuals. With a strict commitment to quality care, adherence to the highest ethical standards and constant attention to administrative responsiveness, speed and accuracy... We Work For Your Benefit. Inc. is licensed as a Dental Plan Organization in Virginia, Maryland and Delaware, a Risk Assuming PPO in Pennsylvania and an Accident and Health Insurer in D.C. The Dominion group of companies includes Inc., the licensed underwriter of the dental plans, and Dominion Dental Services USA, Inc., a licensed administrator of dental and vision benefits.
Inc. (Dominion) is pleased to offer federal employees and their families a choice between three unique dental plan options - two types of Select Plans (same as a DHMO) and the AccessPlus PPO. More choices. More value. How does Federal Dental benefit you? Federal Dental offers three benefit options: Select Plans 603x and 605x: Our carefully chosen Select Plan network dentists provide all the services listed in the Select Plan 603x and Select Plan 605x Summary of Benefits and Member Copayments including many no-charge procedures and others at fees up to 70% lower than usual and customary charges. AccessPlus PPO: This plan combines extensive benefits and the flexibility to use any dentist. Using an AccessPlus PPO network dentist may significantly reduce your out-of-pocket costs. Visit bcbsde.com/federaldental for a complete listing of Select Plan and AccessPlus PPO network dentists. Who is eligible? You and your dependents are eligible. Dependents include your spouse and unmarried children up to age 26. This offer is contingent on your being covered under the BCBS Service Benefit Plan Basic or Standard Option. How do I enroll? If you prefer, you may enroll online at bcbsde.com/federaldental. Online enrollment is quick, convenient and secured by advanced encryption technology. Or:. Choose which benefit you will enroll in and fill out the attached enrollment card. Be sure to list all dependents, if covered, and the dental office of your choice (required for Select Plan subscribers only). 2. Fill out the payment authorization card. 3. Return the completed enrollment card and the payment authorization card to: BCBSD Federal Dental Plans, P.O. Box 7534, Charlotte, NC 28275-534. When will benefits begin? The sooner you apply, the sooner you will be eligible for benefits. If you enroll online or your application is received by the last day of any given month, then your coverage will become effective the first of the next month. When you enroll, you will receive membership ID cards on or before your first day of eligibility at your home address. Can I make changes on the Internet? Yes. Dominion provides members with secure online access to: ID card requests Plan information Dentist search Dental office transfers (Select Plan only) Contact information Member services requests General correspondence All changes are confirmed by return email. For more information, visit us at bcbsde.com/federaldental. Is Federal Dental a FEHB/FEDVIP benefit? No. This benefit is not an FEHB/FEDVIP program or endorsed by OPM. What is my cost? The below rates are valid for subscribers with coverage effective dates beginning between December, 20 and November, 202. Subscribers rates are guaranteed for twelve (2) months following their effective date. Rates are deducted on a monthly basis. 20/202 Bi-Weekly Rates (Monthly Rates) Employee Employee + One Family Select Plan 603x $6.99 ($5.5) $2.94 ($28.03) $8.44 ($39.95) Select Plan 605x $8.94 ($9.38) $6.87 ($36.55) $24.03 ($52.06) AccessPlus PPO $0.09 ($2.86) $9.24 ($4.68) $27.02 ($58.55) Same as a DHMO with fixed member copayments, no annual maximum dollar limits, no waiting periods, no deductibles, no pre-authorization paperwork or pre-treatment estimates and no claim forms (except in the case of out-of-area emergencies). Note: If there is ever a lapse in your monthly payment, a re-enrollment fee and/or waiting periods may apply. bcbsde.com/federaldental 5 South Union Street Suite 300 Alexandria, VA 2234 703-58-5338 (Phone) 703-58-0627 (Fax) 888-58-5338 (Toll Free - Member Services) We Work For Your Benefit.
Select Plan Options- 603x and 605x Summary of Benefits & Member Copayments - Select Plans What are the Select Plan benefits? The Select Plan is the same as a Dental HMO with fixed member copayments, no annual maximum dollar limits, no waiting periods, no deductibles, no pre-authorization paperwork or pre-treatment estimates and no claim forms (except in the case of out-of-area emergencies). Select Plan benefits include: No charge for oral exams No charge for routine semiannual cleanings (Select 605x) No charge for bitewing X-rays No charge for topical fluoride for children These procedures account for over 65% of dental services most frequently performed for adults, and almost 90% of the most frequently performed services for children. 2 You will receive more extensive care (fillings, crowns, dentures, root canals, periodontal care, oral surgery, etc.) at fees up to 70% lower than usual and customary charges. Orthodontic benefits for adults and children are also covered (see Savings Comparison chart). You only pay the amount listed. Specialty care is also provided by Plan Specialists at rates 25% less than usual and customary charge (Specialty care in Delaware may differ). Out-of-area emergency care reimbursement requires a receipt or other proof of loss. 2 Inc. - based on annual review of utilization data. 3 Inc. Competitive Network Survey, 2 nd Quarter 20. Includes D.C., Delaware, Maryland, Pennsylvania and Virginia. 4 Inc. Network Analysis Report, March 200. 5 Based on the Captiva context fee schedule s 80th percentile fee information. 6 There is a $0 office visit fee. Your choice of participating dentists Dominion has one of the largest HMO-style networks in the Mid-Atlantic. 3 Ninety-five percent of Dominion members have access to at least two Select Plan dentists within 0 miles. 4 You may select any general dentist from our list of participating dentists. Each family member may select a different participating dentist. If you need specific information about these offices or if you ever need to change your dentist for any reason, just access our website at bcbsde.com/federaldental or call our Member Services Department toll-free at 888-58-5338. Our network of participating dentists provides: Treatment that emphasizes prevention and early detection of dental problems Extensive coverage (over 250 procedures) Quality dental care at predetermined fees Your choice of convenient private offices Out-of-area emergency care You are covered for up to $00 for palliative emergency dental treatment arising from accidental injury or illness while temporarily more than 50 miles from home. Simply use any convenient dentist and submit the receipt to Dominion for reimbursement. The $00 limit does not apply in Pennsylvania. Savings Comparison Select Plan 603x Select Plan 605x Procedure Average Charge 5 Your Fee 6 Your Savings Your Fee 6 Your Savings Oral Exam $90 No Charge 00% No Charge 00% Bitewing X-rays (2 Films) $4 No Charge 00% No Charge 00% Topical Fluoride for ren $39 No Charge 00% No Charge 00% Semiannual Cleaning (Adult) $97 $3 87% No Charge 00% Complete Series X-rays $34 $26 8% $26 8% Filling (3-Surface/Silver) $93 $58 70% $52 73% Extraction, Erupted Tooth $44 $62 57% $57 60% Crown (Porcelain/Metal) $,38 $497 56% $470 59% Root Canal (Anterior Tooth) $935 $296 68% $282 70% Complete Denture $,474 $606 59% $577 6% Orthodontics $6,863 $3,422 50% $3,422 50% Adult Orthodontics $5,994 $3,658 40% $3,658 40% Diagnostic/Preventive 603x Fees 605x Fees Office visits (incl. sterilization charge)... $0... $0 Oral examinations and diagnosis... No Charge...No Charge X-rays: Complete series...26... 26 Single periapical... No Charge...No Charge Bitewing... No Charge...No Charge Panoramic X-rays...30... 30 Each additional film... No Charge...No Charge Pulp vitality test... No Charge...No Charge Diagnostic models... No Charge...No Charge Semiannual teeth cleaning...3...no Charge Topical fluoride for children... No Charge...No Charge Nutritional counseling... No Charge...No Charge Oral hygiene instruction... No Charge...No Charge Sealant - per tooth (up to age 4)...2... 8 Space maintainers: Unilateral...35... 29 Bilateral...87... 74 Recementation...32... 3 Emergency (palliative) treatment per visit..40... 40 Local anesthesia... No Charge...No Charge Nitrous oxide (per visit - if available)...35... 35 Second opinion/consultation, per session (by another plan dentist)...40... 39 Broken appointments (without 24 hours notice - per /2 hour)...23... 23 Restorative Dentistry (Fillings) Amalgam restorations (silver): One-surface filling, primary/permanent...37... 33 Two-surface filling, primary/permanent.46... 4 Three-surface filling, primary/permanent..58... 52 Four-or-more-surface filling, primary/permanent...70... 62 Resin composite restorations (tooth colored): One-surface filling, anterior...66... 6 Two-surface filling, anterior...79... 73 Three-surface filling, anterior...95... 86 Four-or-more-surface filling, anterior..4... 04 Pin retention (per tooth, add to restoration)..20... 20 Pulp cap direct/indirect (excl. final restoration)...27... 24 Sedative filling...37... 35 Crown & Bridge (Caps, Fixed Tooth Replacement) Inlay - one, two or three surface...407... 390 Onlay - two-surface...458... 423 Resin crown (lab processed)...258... 246 Temporary crown (in conj. w/ perm. crown). No Charge...No Charge Resin with metal crown...495... 470 Porcelain crown fused to metal...497... 470 Full cast crown...470... 457 Recementation: inlay/crown per unit...40... 38 Cast post and core in addition to crown...76... 7 Prefabricated post and core in add. to crown...46... 40 Stainless steel crown (primary or permanent) 4... 2 Core build-up, including any pins...8... 3 Crown repair (by report)...96... 88 Pontics Cast (metal)...470... 457 Porcelain with metal...497... 470 Resin with metal...495... 470 Bridge Retainers Retainer - cast metal for resin bonded fixed.238... 22 Abutment crown - resin with metal...495... 470 Abutment crown - porcelain fused to metal..497... 470 Crown - 3/4 cast high noble metal...470... 457 Prosthetics (Removable) Complete denture - upper or lower...606... 577 Immediate denture - upper or lower...627... 65 Partial denture: Upper/lower resin base with conventional clasps/rests...564... 533 Upper/lower cast metal base with resin saddle...652... 627 Removable unilateral partial - one-piece cast met with clasps and pontics...364... 345 Interim complete/partial dentures (upper/lower)...34... 289 Complete denture adjustments...33... 30 Reline - lab, complete/partial denture...94... 86 Tissue conditioning upper/lower per unit...68... 65 Repairs: Repair complete denture base...75... 73 Replace missing/broken tooth complete denture (per tooth)....75... 73 Clasp added to partial denture...00... 97 This is only a summary of the 252 procedures that are covered. Endodontics (Root Canal) 603x Fees 605x Fees Pulpotomy... $70... $70 Anterior...296... 282 Bicuspid...363... 343 Molar...444... 423 Apicoectomy - anterior...280... 269 Apicoectomy - bicuspid...36... 289 Apicoectomy - molar (first root)...363... 329 Apicoectomy - (each additional root)...32... 28 Retrograde filling (per root)...03... 98 Periodontics (Gum Treatment) Gingivectomy per quad (4 or more teeth)...255... 242 Gingivectomy per quad (-3 teeth)...9... 86 Gingival flap surgery per quad...36... 296 Gingival flap surgery per quad (-3 teeth)...97... 82 Osseous (bone) surgery per quad (-3 teeth).359... 329 Periodontal scaling and root planing per quad.99... 96 Periodontal maintenance procedures...67... 60 Oral Surgery Extraction, without complication...50... 40 Root removal - exposed roots...62... 57 Surgical extraction, erupted...20... 5 Impaction: Soft tissue...37... 30 Partially bony...78... 7 Completely bony...29... 206 Residual tooth root removal...28... 23 Alveoloplasty per quad...28... 22 As performed by a General Dentist. See Plan Exclusion #6 below. Orthodontics Initial records and study models...43... 43 Two-year case (child)... 3,422...3,422 Two-year case (adult)... 3,658...3,658 Plan Exclusions. Services for injuries or conditions which are covered under worker s compensation and employer s liability laws. Services which are provided without cost to Subscribers by any federal, state, municipal, county, or other subdivision s program (with the exception of Medicaid). 2. Services which, in the opinion of the attending dentist, are not necessary for the patient s dental health. 3. Cosmetic, elective or aesthetic dentistry. 4. Oral surgery requiring the setting of fractures or dislocations. 5. Services with respect to malignancies, cysts or neoplasms, hereditary, congenital, anodontic, mandibular prognathism or development malformations where, in the sole discretion of the Participating Dentist, such services should not be performed in a dental office. 6. Dispensing of drugs. 7. Hospitalization for any dental procedure. 8. Treatment required for conditions resulting from major disaster, epidemic or war, including declared or undeclared war or acts of war. 9. Replacement due to loss or theft of prosthetic appliance. 0. General anesthesia and sedation.. Services that cannot be performed because of the general health of the patient (exclusion does not apply in Virginia). 2. Implantation and related restorative procedures. 3. Unlisted procedures are not covered. 4. Services obtained outside of the dental office in which enrolled and which are not pre-authorized by such office or Dominion Dental Services, Inc. (with the exception of out-of-area emergency dental services). 5. Services related to the treatment of TMD (Temporal Mandibular Disorder). 6. Services related to procedures which are of such a degree of complexity as to not be normally performed by a Participating General Dentist. Above copayments do not apply when performed by a Plan Specialist (with the exception of Orthodontics). Plan Specialist, if available, will reduce fees 25% from Usual, Customary, and Reasonable (UCR) fees, except in the State of Delaware. In Delaware, Plan Specialists will provide a reduction from their UCR that will vary between specialists. 7. Elective surgery including, but not limited to extraction of non-pathologic, asymptomatic impacted teeth. 8. The Invisalign system and similar specialized braces are not a covered benefit. Patient copayments will apply to the routine orthodontic appliance portion of services only. Additional costs incurred will become the patient s responsibility. Plan Limitations. Replacement of a bridge, crown or denture within 5 years after the date it was originally installed. 2. Replacement of filling within 2 years after original date of placement. 3. Teeth cleaning (Prophylaxis) at intervals of less than six months. 4. Crown and bridge fees apply to treatment involving five or fewer units when presented in a single treatment plan. Additional crown or bridge units, beginning with the sixth unit, are available at the provider s Usual, Customary, and Reasonable (UCR) fee, minus 25%. 5. Full mouth x-rays or panoramic film one set every three years. 6. Retreatment of root canal within 2 years of the original treatment. 7. Limit 438 to one benefit per tooth for three teeth per quadrant or a total of 2 teeth for all four quadrants per twelve (2) months. Must have pocket depths of five millimeters or greater.
AccessPlus PPO Plan Summary of Coverage Schedule - AccessPlus PPO What are the AccessPlus PPO benefits? The AccessPlus PPO combines the best aspects of PPO and Select Plan benefits in one simple plan. Your coverage under the AccessPlus PPO includes all of the extensive services in the Summary of Coverage Schedule listed inside this brochure and more. You may use any licensed dentist or one of our participating AccessPlus PPO dentists (visit us at bcbsde.com/federaldental for a listing of participating AccessPlus PPO providers near you). When you or your dependents incur expenses for covered dental services, payments will be made in accordance with the list of benefits and services in your Coverage Schedule. Participating dentists are qualified practitioners, licensed and regulated by the appropriate government agencies. By receiving your dental care from a network dentist you benefit from our pre-negotiated fee schedules. Using an AccessPlus PPO dentist can significantly reduce your out-of-pocket costs. How does the AccessPlus PPO work? Most of the commonly practiced diagnostic, preventive, basic and major restorative care dental procedures are covered. Payment for these services is subject to the restrictions identified in the Plan Exclusions section of this brochure. When members receive care from a network dentist, the In-Network column of the Coverage Schedule applies. This is the member s portion of the payment due to the dentist. We will pay the dentist for the balance due. When members receive care from a nonparticipating dentist, the Out-of-Network column of the Coverage Schedule applies. This is the amount we will pay the dentist toward the total cost. The member s portion of the payment due is the difference between the payment we make and the amount billed. The AccessPlus PPO features: Maximum access Use any provider or one of over 5,000 dentist access points nationwide for greater savings Defined in-network copayments make dental costs predictable No charge for in-network exams, cleanings, X-rays and other preventive services No deductibles ($0 office visit fee only) An annual $,000 maximum limit per insured person No waiting periods for diagnostic and preventive care. To be eligible for basic care, you must have completed six months of continuous coverage. For major restorative care, you must have completed 8 months of continuous coverage. No pre-existing condition exclusions Please see the AccessPlus PPO Plan Exclusions. Savings Comparison In-Network Out-of-Network Procedure Average Charge Your Fee 2 Your Savings We Pay You Pay 2 Oral Exam $90 No Charge 00% $32 Bitewing X-rays (2 Films) $4 No Charge 00% $8 Topical Fluoride for ren $39 No Charge 00% $4 Semiannual Cleaning (Adult) $97 No Charge 00% $38 Patient pays Complete Series X-rays $34 No Charge 00% $57 the balance of Filling (3-Surface/Silver) $93 $22 89% $5 the dentist s fee. Extraction, Erupted Tooth $44 $40 72% $46 Crown (Porcelain/Metal) $,38 $34 72% $283 Root Canal (Anterior Tooth) $935 $96 79% $65 Complete Denture $,474 $448 70% $289 Based on the Captiva context fee schedule s 80th percentile fee information. 2 There is a $0 office visit fee. In-Network Out-of-Network Diagnostic/Preventive Care: (Your Copay) (Plan pays) Office visit... $0...$0 Periodic oral examination...0...8 X-rays: Complete series (incl. bitewings)...0...57 Intraoral - periapical - first film...0... Bitewing - single film...0...2 Bitewings - two films...0...8 Panoramic film...22...53 Diagnostic casts...0...39 Prophylaxis (teeth cleaning) - adult...0...38 Prophylaxis (teeth cleaning) - child...0...26 Topical fluoride (incl. prophylaxis) - child..0...36 Space maintainer - fixed - unilateral...0...69 Space maintainer - fixed - bilateral...8...9 Recementation of space maintainer...26...5 Local anesthesia...0...8 Basic Care: Restorative Dentistry (Fillings) Amalgam restorations (silver): One surface, primary or permanent...5...32 Two surfaces, primary or permanent..8...42 Three surfaces, primary or permanent..22...5 Resin composite restorations (tooth colored): One surface, anterior...39...38 Two surfaces, anterior...46...48 Three surfaces, anterior...53...59 Sedative filling...26...22 Major Restorative Care: Crown and Bridges (Caps - Fixed Tooth Replacement) Inlay - metallic - two surfaces...252...26 Inlay - metallic - three or more surfaces..252...249 Onlay - metallic - two surfaces...294...244 Onlay - metallic - three surfaces...330...255 Inlay - porcelain/ceramic - two surfaces..256...236 Inlay - porcelain/ceramic - three or more surfaces...273...252 Onlay - porcelain/ceramic - two surfaces.284...244 Onlay - porcelain/ceramic - three surfaces...295...264 Inlay - composite/resin - two surfaces (lab processed)...224...75 Inlay - composite/resin - three or more surfaces (lab proc)...224...84 Crown - porcelain fused to high noble metal..34...283 Crown - full cast high noble metal...302...273 Pontic - cast high noble metal...302...26 Pontic - porcelain fused to high noble metal.34...258 Pontic - resin with predominantly base metal.269...234 Recement crown...27...22 Prefab. stainless steel crown (not in conj. w/ perm. crown)...86...66 Core buildup, including any pins...74...56 Endodontics (Root Canal Therapy) Anterior (excluding final restoration)...96...65 Bicuspid (excluding final restoration)...252...202 Molar (excluding final restoration)...34...260 anterior...79...89 bicuspid (first root)...202...206 molar (first root)...23...233 Retrograde filling - per root...67...57 Periodontics (Gum Treatment) Gingivectomy or gingivoplasty - per tooth.56...46 Gingival curettage, surgical, per quad., by report...84...62 Gingival flap procedure, incl.. root planing - per quad....24...203 Osseous surgery - one to three teeth per quad....225...20 Perio scaling and root planing - per quad. 73...56 Periodontal maint procedures (following active therapy)...56...34 Prostodontics (Dentures) Complete denture - upper or lower...448...289 Immediate denture - upper or lower...469...35 Denture Repairs: Repair broken complete denture base..56...32 Replace missing or broken teeth - (each tooth)...56...26 Repair or replace broken clasp...73...45 In-Network Out-of-Network (Your Copay) (Plan pays) Oral Surgery Single tooth...2...44 Root removal - exposed roots...67...50 Surgical removal of erupted tooth...78...60 Impaction: Soft tissue... $95...$75 Partially bony...2...00 Completely bony...40...7 * This is only a summary of the 300 procedures that are covered. Visit bcbsde.com/federaldental for a complete list. Plan Exclusions:. Treatment required for conditions resulting while on active duty as a member of the armed forces of any nation or from war or acts of war, whether declared or undeclared. 2. Services which are covered under Medicare, worker s compensation, employer s liability laws, or the Pennsylvania Motor Vehicle Financial Responsibility Law. 3. Services and treatment provided without charge or for which there would be no charge in the absence of insurance. 4. Services not listed as covered. 5. Hospitalization for any dental procedure. 6. Services and treatment for which Member is eligible for coverage under his or her hospital, medical/surgical or major medical plan. 7. Reconstructive, plastic, cosmetic, elective or aesthetic dentistry. 8. Elective surgery including, but not limited to, extraction of non-pathologic, asymptomatic impacted teeth. 9. Replacement of dentures, bridges, inlays, onlays or crowns that can be repaired or restored to normal function. 0. Replacement of lost, stolen or damaged prosthetic or orthodontic appliances; athletic mouthguards; precision or semiprecision attachments; denture duplication; sealants; periodontal splinting of teeth.. Services for increasing vertical dimension, restoring occlusion, replacing tooth structure lost by attrition, and correcting developmental malformations and/or congenital conditions. 2. Oral hygiene instructions; plaque control; completion of a claim form; acid etch; broken appointments; prescription or take-home fluoride;or diagnostic photographs. 3. Dispensing of drugs. 4. Diagnosis or treatment of temporomandibular joint (TMJ) syndromes, problems and/or occlusal disharmony. 5. Procedures that in the opinion of Dominion Dental Services are experimental or investigative in nature because they do not meet professionally recognized standards of dental practice and/or have not been shown to be consistently effective for the diagnosis or treatment of the Member s condition. 6. Treatment of cleft palate, anodontia, malignancies or neoplasms. 7. Any service or supply rendered to replace a tooth lost prior to the effective date of coverage. This exclusion expires after 36 months of Member s continuous coverage under the plan. 8. Maryland policyholders only: Any bill, or demand for payment, for a dental service that the appropriate regulatory board determines was provided as a result of a prohibited referral. Prohibited referral means a referral prohibited by Section -302 of the Maryland Health Occupations Article. Claims filing Benefits will be paid to you or they may be assigned directly to your dentist. Claim forms should be completed by your dentist at the time services are rendered. Your dentist may use the standard American Dental Association approved claim form and file the claim electronically. AccessPlus PPO Claims Should Be Mailed To: Dominion Dental Services P.O. Box 26 Elk Grove Village, IL 60009 Or Fax Claims To: 888-208-8290
DOMINION DENTAL SERVICES PAYMENT AUTHORIZATION CARD PAY BY CREDIT CARD DEBIT: AUTOMATIC MONTHLY DEBITS ANNUAL PAYMENT Credit Card Number: OUR PRE-AUTHORIZED PAYMENT PLAN Just authorize us to debit your personal checking account or credit card account and we ll do the rest. Whether you choose the monthly or annual option with automatic deductions there will be no more paperwork, no more checks to write and no worries about coverage disruption. It s easy, secure, and automatic. Credit Card Type: Visa MasterCard American Express Discover Name as it appears on card: Expiration Date: PAY BY CHECKING ACCOUNT DEBIT: AUTOMATIC MONTHLY DEBITS ANNUAL PAYMENT Bank Name: Bank Routing Number: Bank Account Number: * By submitting a check for the rst month s premium and application fee, you authorize Inc. to automatically deduct future monthly premium payments from your checking account. TERMS AND AUTHORIZATION Payment Authorization: By signing the Payment Authorization form you authorize Dominion Dental Services, Inc., to automatically deduct premium payments from the credit card or checking account noted above. By selecting the Automatic Monthly Debits option you further agree to automatic deductions of future monthly premiums. Application Fee: There is a one-time, non-refundable $20 application fee. When paying by Automatic Monthly Debit to your checking account or credit card account, you will be charged the application fee along with your rst month s premium. When paying by Annual Payment you will be charged for 2 months of premium plus the $20 application fee. FEE WAIVED FOR A LIMITED TIME ONLY! Pay By Credit Card: By selecting the Automatic Monthly Debits option you authorize Dominion Dental Services, Inc. to automatically deduct future monthly premium payments from your credit card account. Pay By Bank Account Debit: By selecting the Automatic Monthly Debits and submitting a voided check you authorize Inc. to automatically deduct future monthly premium payments from your checking account. TERMS: This authorization will remain in effect unless 30 days advance written notice of termination is received by Inc. In the event that any electronic debit or transfer is returned, I agree that a $25.00 returned item fee will be automatically charged to my account. AUTHORIZATION: I authorize Inc. to automatically deduct the premium and application fee from any credit card OR bank account stated above. Members who choose the Automatic Monthly Debits will be debited on or about the 20th of each month. Signature: Date: Agent/Broker Use Only Agent/Broker # General Agent # As listed on your health insurance card: BCBS Federal ID #: R Enroll. Code: DOMINION DENTAL SERVICES, INC. ENROLLMENT CARD Enrollment Information Last Name First Name M.I. Social Security Number Sex M Birthdate (MM/DD/YY) F Home Address Home Phone City State ZIP Work Phone Email Address Hire Date List All Your Eligible Dependents Below Last name (if different) First Name M.I. Sex (M/F) Birthdate (MM/DD/YY) Spouse Select Plan/AccessPlus PPO Enrollment Card You can also enroll securely online at bcbsde.com/federaldental SELECT PLAN Provider Selection SELECT ONE: Dental Of ce Name & Code # (As Indicated on Your Dentist Directory) Select Plan 603x Select Plan 605x AccessPlus PPO Agent/Broker # Group # Group Name Coverage Eff. Date Federal Dental BCBSD Inc., P.O. Box 7534 Charlotte, NC 28275-534