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| DISCLOSURE FORM / CONTRACT ("CONTRACT") |
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This booklet is a Disclosure Form/Contract ("Contract") for your Individual/Family Dental HMO Program ("Program") provided by:
ALPHA Dental Programs ("ALPHA") dba DeltaCare USA
a Single Service Health Maintenance Organization ("HMO")
700 Parker Square
Suite 150
Flower Mound, Texas 75028
(800) 422-4234
Administrative functions described throughout this booklet may be performed by Delta Dental Insurance Company ("Delta Dental "), a third party administrator, as designated by ALPHA.
The booklet discloses the terms and conditions of the Program available in Texas. PLEASE READ THE ENTIRE DOCUMENT COMPLETELY AND CAREFULLY. You have a right to review this Contract prior to enrollment.
PLEASE READ THE FOLLOWING INFORMATION SO THAT YOU WILL KNOW HOW TO OBTAIN DENTAL SERVICES. YOU MUST OBTAIN DENTAL BENEFITS FROM (OR BE REFERRED FOR SPECIALIZED SERVICES BY) YOUR ASSIGNED CONTRACT DENTIST.
ADDITIONAL INFORMATION ABOUT YOUR BENEFITS IS AVAILABLE BY CALLING THE CUSTOMER SERVICE DEPARTMENT AT (800) 422-4234, 7 a.m. - 8 p.m. CENTRAL TIME, MONDAY THROUGH FRIDAY. THESE CALLS WILL BE ANSWERED BY ALPHA'S ADMINISTRATOR, DELTA DENTAL INSURANCE COMPANY. |
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