9225 Ulmerton Road Ste 310 Largo, FL 33771     Phone: (727) 210-0980    Fax: (727) 210-0747

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DENTAL ENROLLMENT APPLICATION

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First Name (*)
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Last Name ( Jr., Sr., etc.) (*)
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M.I.
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Home Telephone (*)
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E Mail (*)
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Date of Birth (*) / /
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Marital Status (*)
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* required field

City (*)
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State (*)
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Street Address (*)
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Apt Number
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Zip (*)
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Sex / Gender (*)
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Select a Plan From Smile or Master


SmilePlan:

 DENTAL CARE & FEATURE BENEFITS

Personal Choice of Dental Network-Over 5,600 Locations
No Deductibles
No Annual Maximums
No Waiting Periods
No Claims Forms
No Pre-Authorizations
Over 60,000 Retail Prescription Locations
20-50% off Prescriptions
Up to 15% off Hearing Aids
Free Hearing Screening
Over 45,000 Vision Providers
Up to 60% off Vision Care




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MasterPlan:

DENTAL CARE & FEATURE BENEFITS

Personal Choice of Dental Network
No Deductibles
No Annual Maximums
No Waiting Periods
No Pre-Existing Condition Exclusions
No Charge for X-rays
No Charge for Fluoride Application
No Charge Routine Cleanings (2 per year)
No Charge for Comprehensive Exams
No Claims Forms
No Pre-Authorizations
Vision Discounts

 



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Add a Spouse to Dental Plan


Spouse Name
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Date of Birth (MM-DD-YY) / /
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Sex / Gender of Spouse
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Add a Child to Dental Plan


Child Name
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Date of Birth (MM-DD-YY) / /
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Child Name
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Date of Birth (MM-DD-YY) / /
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Child Name
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Date of Birth (MM-DD-YY) / /
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DEPENDENTS: Eligible dependents include your spouse and/or
unmarried children from birth to 19 yrs. of age, or 25 yrs. of age
if a Full- time student or fully dependent on you for support.


DEPENDENTS * 


Sex / Gender of Child
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STUDENT (Over Age 19)
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Sex / Gender of Child
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STUDENT (Over Age 19)
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Sex / Gender of Child
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STUDENT (Over Age 19)
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First Name (*)
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Last Name (Include Jr., Sr., etc.) (*)
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Add letters to Validate (*) Add letters to Validate
  Refresh
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Digital Signature
I am applying for dental coverage and by my dgital signature I understand this dental plan is a (1) year non-refundable program. I authorize the dentist who has rendered services to me or members of my family to make available to Argus Dental & Vision, Inc. my dental records, photocopies or information regarding such services to the extent permitted by law. If information is not complete and your signature is not present, the application will not be processed.. Any person who knowingly and with intent to injure, defraud or deceive any insurer, files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree.