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TRANSCRIPT
Don’t wait until it’s too late!
Get your
SmartSmilesm today!
Protecting your mouth Advocating for your health
205 SE Spokane Street, Suite 334Portland, Oregon 97202
T: 503-281-1771 F: 503-238-7500
A Great Reason to Smilesm
SmartSmilesm dental plans are exclusively provided by:
For Individuals & FamiliesCertified by Cover Oregon to Satisfy the Essential Pediatric Dental Benefit
1013OG014 dba Dental Health Services, Your Dental Plan
CodeProcedureRegular Fee**SmartSmilesmSuper SmartSmilesmSmartSmile Plussm
PediatricAdultPediatricAdultPediatricAdult
D1110Teeth cleaning (prophylaxis)
$105$25 (76%)$25 (76%)$25 (76%)$5 (95%)$0 (100%)$5 (95%)
D1351Sealant - per tooth$63$5 (92%)$5 (92%)$5 (92%)$5 (92%)$2 (97%)$5 (92%)
D2150Amalgam - two surfaces, primary or permanent
$217$40 (82%)$52 (76%)$25 (88%)$35 (84%)$25 (88%)$35 (84%)
D2750Crown - porcelain fused to high noble metal
$1,301$625 (52%)$625 (52%)$625 (52%)$625 (52%)$625 (52%)$625 (52%)
D7210Surgical Extraction$325$110 (66%) $134 (58%)$110 (66%) $135 (58%)$110 (66%) $135 (58%)
Your SmartSmilesm plan gives you the care you need and coverage you want
Get comprehensive benefits for less than the price of a pair of movie tickets
Enjoy significant savings on the most common dental procedures
Enrolling is easy and simple! Unfold this page for more information.
Help is only a call or click away. You can reach us at 503-281-1771 or at
[email protected]. We’re always happy to help you!
A Great Reason to Smilesm
** Regular fees are based on the 90th percentile of the usual and customary fees for each service, per the 2013 NDAS Fee Information.
*Spouse/Domestic Partner
SmartSmilesm
Prepaid Dental Plans
Enjoy dental coverage you can rely onMore than 300 general dental procedures are covered, from exams to x-rays, cleanings, crowns, dentures, extractions, amalgam & composite restorations, sealants, and bridges. With low out-of-pocket copayments, your SmartSmilesm plan meets your dental care needs and budget.
Rest easy with prompt service & treatmentYou get the help you need, with easy appointment scheduling, no waiting periods, no pre-existing condition exclusions, and no annual maximums.
Get care from a Quality Assured dentistYou will receive excellent care from your selected Quality Assured dentist in our network. All of our local dental offices are independently owned and adhere to our 107-point Quality Assurancesm program for treatment and service.
Save valuable time and moneySmartSmilesm plans have no deductibles and do not require pre-authorizations for services received at your selected participating dental office.
Work with dedicated employee-ownersIndependently operated for more than 38 years, Dental Health Services is the only employee-owned dental benefits company in the country. When you work with us, you will be helped quickly and easily by one of our experienced Member Service Specialists.
“I have used Dental Health Services plan for many years and am very pleased with their customer service. In my personal experience with them, I or my dentist have never encountered a problem which says a lot about their professionalism and their concern for their clients. I would highly recommend Dental Health Services to anyone.”
- Maria F., California Member
Braces and dentures are coveredEnjoy orthodontia benefits (braces) as well as coverage for dentures with great savings when you receive care from a participating Dental Health Services orthodontist or denturist.
Simple, easy-to-understand copaymentsCopayments are set and easy to understand. You know exactly how much you’ll owe before you even schedule your appointment. Enjoy affordable, has-sle-free coverage with no surprises!
Choose the best plan for youChoose between a lower monthly payment with SmartSmilesm, or you can pay less out of pocket for basic procedures with Super SmartSmilesm or SmartSmilesm Plus.
Exchange-Certified, Qualified Dental PlansAll SmartSmilesm plans are Cover Oregon-certified. Any SmartSmilesm dental plan you select satisfies the essential pediatric dental plan requirements set by the Affordable Care Act.
Clear, hassle-free benefitsSmartSmilesm plans include no waiting periods, no deductibles, no maximums, no pre-existing condition exclusions, and no claim forms.
Enroll in minutesYou can enroll online at www.smartsmile.com or complete the enrollment form inside this brochure and mail it to us. You just need to select your den-tist, record your contact information and include your method of payment. It’s that easy!
INDIVIDUAL COVERAGESmartSmilesmSuper SmartSmilesmSmartSmile Plussm
MONTHLYANNUALMONTHLYANNUALMONTHLYANNUAL
Pediatric Child (18 years old & under)$27.50$330.00$27.50$330.00$33.25$399.00
Dependent Child (19-25 years old)$14.25$171.00$21.75$261.00$21.75$261.00
Adult (Primary Subscriber/Spouse*) $16.75$201.00$25.75$309.00$25.75$309.00
1013OG014 dba Dental Health Services, Your Dental Plan
Den
tal
Hea
lth S
ervi
ces
was
fou
nded
in
1974
by
God
frey
Per
nell,
DD
S. A
pio
neer
in
the
den
tal
ind
ustr
y, D
r. Pe
rnel
l op
ened
the
first
pre
pai
d d
enta
l fa
cilit
y in
the
1950
s to
ans
wer
the
call
of la
bor
uni
ons
seek
ing
bet
ter
den
tal c
are
for
thei
r w
orke
rs.
Driv
en b
y th
e sa
me
pas
sion
to
serv
e m
ore
peo
ple
ne
edin
g q
ualit
y, a
fford
able
den
tal c
are,
Dr.
Pern
ell
esta
blis
hed
Den
tal H
ealth
Ser
vice
s as
one
of t
he fi
rst
den
tal
ben
efit
com
pan
ies
to s
pec
ializ
e in
pre
pai
d
den
tal
pla
ns.
The
inno
vativ
e co
ncep
t -
pre
pai
d
den
tistr
y -
chan
ged
ind
ustr
y st
and
ard
s fo
r se
rvic
e an
d c
are,
and
pro
vid
ed a
new
and
effe
ctiv
e w
ay t
o d
eliv
er h
igh-
qua
lity
den
tal c
are
affo
rdab
ly.
As
a st
rong
ad
voca
te f
or y
our
oral
hea
lth a
nd
wel
lnes
s, D
enta
l H
ealth
Ser
vice
s is
com
mitt
ed t
o hi
gh-
qua
lity
den
tal c
are
and
trea
tmen
t. It
all
beg
ins
with
our
net
wor
k of
Qua
lity
Ass
ured
den
tists
. A
ll of
our
par
ticip
atin
g d
entis
ts u
nder
go
a rig
orou
s 10
7-p
oint
Qua
lity
Ass
uran
cesm
pro
gra
m a
nd a
re
req
uire
d t
o m
aint
ain
hig
h st
and
ard
s. T
his
pro
gra
m
ensu
res
you
rece
ive
the
bes
t ca
re p
ossi
ble
.
Ad
diti
onal
ly,
all o
f ou
r M
emb
er S
ervi
ce S
pec
ialis
ts
who
dire
ctly
ass
ist
you
offe
r ye
ars
of h
and
s-on
, p
rofe
ssio
nal e
xper
ienc
e w
orki
ng in
den
tal o
ffice
s.
A
loca
l, in
dep
end
ent
den
tal
ben
efit
solu
tions
co
mp
any,
D
enta
l H
ealth
Se
rvic
es
has
a ve
sted
in
tere
st
in
imp
rovi
ng
the
oral
he
alth
of
ou
r co
mm
unity
. O
ur l
ocal
ad
vant
age
also
allo
ws
us t
o
qui
ckly
res
pon
d t
o yo
ur c
hang
ing
nee
ds
and
rea
dily
p
rovi
de
per
sona
lized
ser
vice
.
Den
tal
Hea
lth S
ervi
ces
is t
he o
nly
emp
loye
e-ow
ned
d
enta
l b
enefi
ts c
omp
any
in t
he U
nite
d S
tate
s. T
hirt
y p
erce
nt o
f our
com
pan
y is
ow
ned
by
emp
loye
e-ow
ners
w
ho a
ll ha
ve a
sen
se o
f acc
ount
abili
ty t
o ou
r m
emb
ers,
d
entis
ts,
gro
ups,
bro
kers
, an
d t
o ea
ch o
ther
- n
ot t
o co
rpor
ate
shar
ehol
der
s.
As
the
exci
ting
futu
re o
f hea
lthca
re c
ontin
ues
to c
hang
e,
we’
re re
ady
to fo
rge
new
pat
hs, d
evel
op in
nova
tive
and
cu
stom
ized
den
tal
ben
efit
solu
tions
, an
d p
rovi
de
you
with
exc
elle
nt s
ervi
ce a
nd v
alue
...no
w a
nd m
any
year
s in
to t
he fu
ture
.
A L
ong
His
tory
of
Qua
lity,
A
ffo
rdab
le D
enta
l Car
eD
enta
l Hea
lth
Serv
ices
is y
our
loca
l den
tal b
enefi
t so
luti
ons
com
pan
y
Pri
mar
y Su
bsc
rib
er In
form
atio
n
Cho
ose
Yo
ur P
aym
ent
Met
hod
and
Incl
ude
Pay
men
t“M
y m
oth
er
rece
ntly
p
urch
ased
a
Sup
er
Smar
tSm
ile
den
tal
pla
n w
ith
Den
tal
Hea
lth
Serv
ices
. Sh
e w
as
in
need
of
som
e ex
pen
sive
den
tal
wo
rk.
She
cont
acte
d
me
sho
rtly
aft
er h
er i
nitia
l vi
sit
to r
epo
rt h
ow
hap
py
she
was
to
hav
e th
e p
lan
and
the
sig
nific
ant
savi
ngs
it p
ro-
vid
ed f
or
her
upco
min
g d
enta
l w
ork
. Th
e q
uote
she
re
ceiv
ed f
rom
her
den
tist
was
sig
nific
antly
lo
wer
tha
n sh
e ex
pec
ted
. Sh
e w
ill b
e sa
ving
mo
re t
han
half
of
re-
tail
pric
ing
on
her
serv
ices
, an
d s
he w
as a
ble
to
cho
ose
th
e d
enta
l offi
ce s
he w
as f
orm
erly
usi
ng.
She
was
so
im-
pre
ssed
that
she
has
ad
ded
my
fath
er to
her
den
tal p
lan.
”
- Rei
na R
., W
ashi
ngto
n M
emb
er
A G
reat
Rea
son
to S
mile
sm
Last
Nam
e
F
irst
Nam
e
M
.I.
Gen
der
Mar
ital
Sta
tus
P
refe
rred
Lan
gua
ge
Ad
dre
ss
C
ity
Sta
te
Zip
Co
de
E
mai
l
Em
plo
yer
Ho
me
Pho
ne
Wo
rk P
hone
Bir
th D
ate
R
eque
sted
Eff
ecti
ve D
ate
D
enti
st N
umb
er
EN
RO
LLE
ES
TO B
E C
OV
ER
ED
Last
Nam
e
F
irst
Nam
e
M
.I.
G
end
er
Bir
th D
ate
R
elat
ion
to S
ubsc
rib
er
____
____
____
____
____
____
____
____
____
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____
OFF
ICE
U
SE
ON
LY
Che
ck o
r m
oney
ord
er -
ann
ual p
aym
ent
Che
ckin
g w
ithd
raw
al -
aut
omat
ic m
onth
ly p
aym
ents
Cre
dit
card
- a
nnua
l pay
men
t
Cre
dit
card
- a
utom
atic
mon
thly
pay
men
ts
V
isa
M
aste
rCar
d
D
isco
ver
____
____
____
____
____
____
____
____
____
____
____
____
____
___
Cre
dit
Car
d N
umb
er
E
xpir
atio
n
____
____
____
____
____
____
____
____
____
____
____
____
____
___
Am
oun
t (A
nnua
l or
2-m
ont
hs’ P
rem
ium
)
3
-Dig
it C
od
e
____
____
____
____
____
____
____
____
____
____
____
____
____
___
Sig
natu
re
D
ate
You
may
be
guilt
y of
fra
ud a
nd m
ay b
e su
bjec
t to
civi
l or
crim
inal
pen
altie
s if
you
kn
owin
gly
prov
ide
false
, inc
ompl
ete
or m
islea
ding
info
rmat
ion
to a
limite
d he
alth
care
se
rvic
e co
ntra
ctor
for t
he p
urpo
se o
f de
frau
ding
the
com
pany
.
MO
NT
HLY
PA
YM
EN
TS
RE
QU
IRE
AN
IN
ITIA
L 2-
MO
NT
H P
AY
ME
NT,
w
ith th
e tw
o-m
onth
s’ pr
emiu
m h
eld
by D
enta
l Hea
lth S
ervi
ces a
nd u
sed
if a
utom
atic
w
ithdr
awal
is u
nava
ilabl
e du
e to
insu
ffici
ent f
unds
.
The
acc
ount
info
rmat
ion
on th
e en
clos
ed c
heck
or
liste
d cr
edit
card
num
ber
is th
e ac
coun
t fro
m w
hich
you
r pre
miu
m p
aym
ent w
ill b
e w
ithdr
awn.
Aut
omat
ic c
heck
ing
with
draw
al o
r mon
thly
cre
dit c
ard
char
ges
begi
n th
e m
onth
follo
win
g yo
ur e
ligib
ility
da
te, a
nd c
ontin
ue o
n or
afte
r the
fifth
of
each
mon
th y
ou a
re e
nrol
led.
By
sele
ctin
g a
Smar
tSm
ileE
nro
llmen
t Fo
rmsm
Dep
ende
nts i
nclu
de y
our u
nmar
ried
child
ren
unde
r 26
year
s of
age
. Chi
ldre
n 26
yea
rs o
f ag
e an
d ov
er a
re e
ligib
le o
nly
whi
le th
e ch
ild is
and
con
tinue
s to
be b
oth
1) in
ca-
pabl
e of
sust
aini
ng e
mpl
oym
ent b
y re
ason
of
deve
lopm
enta
l disa
bilit
y or
phy
sical
cha
lleng
e, an
d 2)
is c
hiefl
y de
pend
ent u
pon
the
subs
crib
er fo
r sup
port
and
mai
nten
ance
, pr
ovid
ed p
roof
of
inca
paci
ty a
nd d
epen
denc
y is
furn
ished
to D
enta
l Hea
lth S
ervi
ces w
ithin
31
days
of
such
a re
ques
t.
List
ed n
ext t
o yo
ur d
entis
t’s n
ame
in o
ur
Dire
ctor
y of
Par
ticip
atin
g D
entis
ts
mon
thly
pay
men
t opt
ion,
you
her
eby
auth
oriz
e D
enta
l Hea
lth S
ervi
ces t
o w
ithdr
aw
the
appl
icab
le m
onth
ly p
aym
ent f
rom
you
r ac
coun
t. T
he a
utho
rizat
ion
rem
ains
in
full
forc
e an
d ef
fect
for
at
leas
t on
e ye
ar, a
nd r
enew
s au
tom
atic
ally
unl
ess
writ
ten
notic
e is
rece
ived
50
days
prio
r to
the
expi
ratio
n of
the
annu
al te
rm.
By s
ubm
ittin
g th
is fo
rm,
I au
thor
ize
my
dent
ist t
o re
leas
e an
y in
form
atio
n re
-ga
rdin
g m
y pa
tient
hist
ory
to D
enta
l H
ealth
Ser
vice
s, co
nsul
ting
prof
essio
nals,
or
oth
er d
esig
nate
d or
app
rove
d en
titie
s fo
r th
e pu
rpos
e of
cer
tifyi
ng ,
purc
has-
ing,
pro
vidi
ng,
eval
uatin
g or
adm
inist
erin
g be
nefit
s. T
he a
utho
rizat
ion
rem
ains
in
eff
ect
until
rev
oked
by
me
in w
ritin
g. I
also
cer
tify
that
I a
m o
ver
18 y
ears
of
age.
I ag
ree
that
if
I ca
ncel
my
mem
bers
hip
with
in t
he fi
rst
year
I w
ill b
e su
b-je
ct t
o a
$50.
00 c
ance
llatio
n fe
e an
d w
ill r
ecei
ve a
pro
rate
d re
fund
, if
appl
icab
le.
Cho
ose
Yo
ur S
mar
tSm
ilesm
Pla
n
You
can
also
enr
oll o
nlin
e at
ww
w.s
mar
tsm
ile.c
om
*Max
imum
of th
ree p
ediat
ric ch
ildren
will
be c
harg
ed
**S
pous
e/D
omest
ic Pa
rtner
IND
IVID
UA
L C
OV
ER
AG
E
Smar
tSm
ilesm
Sup
er S
mar
tSm
ilesm
Smar
tSm
ile P
lussm
MO
NTH
LYA
NN
UA
LM
ON
THLY
AN
NU
AL
MO
NTH
LYA
NN
UA
L
Prem
ium
No.
of
Enr
olle
esPr
emiu
mN
o. o
f E
nrol
lees
Prem
ium
No.
of
Enr
olle
esPr
emiu
mN
o. o
f E
nrol
lees
Prem
ium
No.
of
Enr
olle
esPr
emiu
mN
o. o
f E
nrol
lees
Ped
iatr
ic C
hild
* (1
8 ye
ars
old
& u
nder
)$2
7.50
$330
.00
$27.
50$3
30.0
0$3
3.25
$399
.00
Dep
end
ent
Chi
ld (1
9-25
yea
rs o
ld)
$14.
25$1
71.0
0$2
1.75
$261
.00
$21.
75$2
61.0
0
Ad
ult
(Pri
mar
y Su
bsc
rib
er/S
pou
se**
)$1
6.75
$201
.00
$25.
75$3
09.0
0$2
5.75
$309
.00
TOTA
L (P
rem
ium
s x
no. o
f en
rolle
es)
A
M
Eff
. Dat
e C
ycle
G
roup
#
Pla
n#
P
/S#
I.
A.#
A
gen
t N
ame
A
gen
t#
1013
OG
014
dba
Den
tal H
ealth
Ser
vice
s, Yo
ur D
enta
l Pla
n10
13O
G01
4 db
a D
enta
l Hea
lth S
ervi
ces,
Your
Den
tal P
lan
Detach the completed form and mail or fax it back to Dental Health Services.