PLAN ID#__________________________ PLAN EFFECTIVE DATE___________________________ POLICY #____________________________(SSN) COUNTY:________________________________ LICENSED AGENTS SIGNATURE OF APPROVAL_____________________________________________ FOR OFFICE USE ONLY Form: APP080109 Application for Prepaid Dental Plan “Plan”
Insured by: Sterling Dental Services, LLC
Administered by Sterling Health Services, LLC Completed Application to be returned to: Sterling Health Services, LLC PO Box 891330 * Oklahoma City, OK 73189‐1330 Phone: 405.728.1278 or 866.632.8882 Fax: 866.346‐6851 PROPOSED INSURED (person who receives dental care) Name:_______________________________________________________ Sex: ____ SSN: __________________________ DOB: ___/_____/_____ Medicaid Number:________________ Medicare Number:_____________ Resident Conditions ___Tube Feeder NPO ___ Tube Feeder not NPO ___ Tracheotomy ___Ventilator ___ HIV ___ Dementia ___ Alzheimer’s PAYOR TYPE ____Medicaid ____ SSI ____ Private ____ Trust ____Facility Pay
APPLICANT (responsible person, if other than proposed Member, who is signing application on behalf of proposed Insured) Name:___________________________ Relationship:_______________________________ Address:__________________________ Phone:_______________ or __________________ City:_____________________________ State:________________ Zip:__________________ PAYMENT METHOD (Person making premiums on behalf of insured) _____Basic Plan ‐ $62.00 (BPA022707) ____Premium Plan $72.00 (PPA022707) Send Bill to: _____Responsible Party _____Facility (c/o Resident) _____Facility/Trust ____ Facility Pay FACILITY WHERE PROPOSED INSURED RESIDES Name:________________________________________________________________________ Address:____________________________________________Phone_____________________ City:______________________________ State:__________________ Zip:_________________ APPLICATION SIGNATURE I understand that coverage will not be effective until this application and applicable payment has been received and accepted. I authorize any dentist to provide the Company, its agents, employees, affiliates, designees, or its administrators involved in evaluating determining, or administering benefits, information concerning advice, care, or treatment provide under the plan. Require
Proposed Member/Responsible Party Signature:_________________________________________ d
AUTO PAYMENT AUTHORIZATION I (We) hereby authorize Sterling Health Services to initiate debit entries to my (our) checking account at the BANK indicated on the attached void check that is made part of this application. This authorization is to remain in full force and effective until Sterling Health Services and BANK receive written notification from me (or either of us) of its termination. By signing below I am representing that I am an authorized signatory on the account referenced by the attached VOIDED check. Auto‐Payment Authorization Signature:__________________________Date:___________________ Recommen
***INCLUDE COPY OF VOIDED CHECK FOR AUTO‐PAYMENT*** TREATMENT CONSENT AUTHORIZATION d d
Consent for Treatment: 1. I hereby authorize doctor or designated staff of Sterling Dental Services to take x‐rays, study models, photographs, and any other diagnostic aids deemed appropriate by doctor to make a thorough diagnosis of above listed proposed insured’s dental needs. 2. Upon such diagnosis, I authorize doctor to perform all recommended treatment mutually agreed upon by me, and/or the proposed insured, and to employ such assistance, as required, to provide proper care. I understand that Sterling Dental Services will not perform procedures prior to obtaining authorization from the responsible party, Long Term Care Facility (if trust) or proposed insured. 3. I agree to the use of anesthetics, sedatives, and other medication as necessary. I fully understand that using anesthetic agents embodies certain risks. Proposed Member/Applicant Signature:___________________________ Date:_______________ Responsible Party Signature:____________________________ Name:________________________
Require
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PRIVACY NOTICE
Sterling Dental Services, LLC
P.O. Box 891330 * Oklahoma City, OK 73189 * (405) 728-1278 * (866) 632-8882
Sterling Dental Services knows that your privacy is important. You have received this notice as required by law and
because you are now or may be a customer of our company. This notice will advise you of the types of Nonpublic
Personal Information we collect, how we use it, and what we do to protect your privacy.
“Nonpublic Personal Information” refers to personally identifiable information that is not available to the public.
“Employees, Representatives, Agents and Selected Third Parties” refers to individuals or entities who act on our
behalf.
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Our Employees, Representatives, Agents and Selected Third Parties may collect Nonpublic Personal Information
about you, including information:
Given to us on applications or other forms;
About transactions with us, or affiliates, or third parties;
From others, such as credit reporting agencies, employers, and federal and state agencies.
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The types of Nonpublic Personal Information we collect depends on the products we offer to you and may
include your: name; address; Social Security Number; account balances; income; assets; insurance premiums;
coverage and beneficiaries; credit reports; marital status; and payment history. We may also collect Nonpublic
Personal Health Information, such as medical reports, to underwrite insurance policies, process claims, or for
other related functions.
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We restrict access to Nonpublic Personal Information to those Employees, Representatives, Agents, or Selected
Third Parties who provide products or services to you and who have been trained to handle Nonpublic Personal
Information as described in this Notice.
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We have policies and procedures that direct our Employees, Representatives, Agents and Selected Third Parties
acting for us, on how to protect and use Nonpublic Personal Information.
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We have physical, electronic, and procedural safeguards in place that were designed to protect Nonpublic
Personal Information.
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We do not share Nonpublic Personal Information about you except as allowed by law.
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We may disclose all types of Nonpublic Personal Information that we collect, including information regarding your
transactions or experiences with us, when needed, to:
(i)
Employees, Representatives, Agents, and Selected Third Parties, as permitted by law
The types of companies and persons to whom we may disclose Nonpublic Personal Information as permitted by
law include: banks; attorneys; trustees; third-party administrators; insurance agents; insurance companies;
insurance support organizations; credit reporting agencies; registered broker-dealers; auditors; regulators; and
reinsurers.
We do not share your Nonpublic Personal Health Information unless authorized by you or allowed by law.
Our privacy policy applies, to the extent required by law, to our agents and representatives when they are acting
on behalf of Sterling Dental Services.
You will be notified if our privacy policy changes.
Our privacy policy applies to current and former customers.
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This Privacy Notice is given to you for your information only. You do not need to call or take any
action.
Form: APP080109