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ured

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Dental Health Services was founded in 1974 by Godfrey Pernell, DDS. A pioneer in the dental industry, Dr. Pernell opened the first prepaid dental facility in the 1950s to answer the call of labor unions seeking better dental care for their workers.

Driven by the same passion to serve more people needing quality, affordable dental care, Dr. Pernell established Dental Health Services as one of the first dental benefit companies to specialize in prepaid dental plans. The innovative concept - prepaid dentistry - changed industry standards for service and care, and provided a new and effective way to deliver high-quality dental care affordably.

As a strong advocate for your oral health and wellness, Dental Health Services is committed to high-quality dental care and treatment. It all begins with our network of Quality Assured dentists. All of our participating dentists undergo a rigorous 107-point Quality Assurancesm program and are required to maintain high standards. This program ensures you receive the best care possible.

Additionally, all of our Member Service Specialists who directly assist you offer years of hands-on, professional experience working in dental offices.

Dental Health Services is a local, independent dental benefit solutions company and has a vested interest in improving the oral health of our community. Our local advantage also allows us to quickly respond to

your changing needs and readily provide personalized service.

Dental Health Services is the only employee-owned dental benefits company in the United States. Thirty percent of our company is owned by employee-owners who all have a sense of accountability to our members, dentists, groups, brokers, and to each other - not to corporate shareholders.

As the exciting future of healthcare continues to change, we’re ready to forge new paths, develop innovative and customized dental benefit solutions, and provide you with excellent service and value...now and many years into the future.

A Long History of Quality, Affordable Dental Care

Dental Health Services is your local dental benefit solutions company

“My mother recently purchased a Super SmartSmile dental plan with Dental Health Services. She was in need of some expensive dental work. She contacted me shortly after her initial visit to report how happy she was to have the plan and the significant savings it provided for her upcoming dental work. The quote she received from her dentist was significantly lower than she expected. She will be saving more than half of retail pricing on her services, and she was able to choose the dental office she was formerly using. She was so impressed that she has added my father to her dental plan.”

- Reina R., SmartSmilesm Member

A Great Reason to Smilesm

Det

ach

the

com

ple

ted

form

and

mai

l or f

ax it

bac

k to

Den

tal H

ealth

Ser

vice

s.

Primary Subscriber Information

Choose Your Payment Method and Include Payment

SmartSmile Monthly Annually Super SmartSmile Monthly Annuallyo Subscriber $17.75 $213.00 o Subscriber $24.25 $291.00o Subscriber & 1 dependent $35.00 $420.00 o Subscriber & 1 dependent $47.25 $567.00o Subscriber & 2 dependents $47.75 $573.00 o Subscriber & 2 dependents $62.50 $750.00o Subscriber & 3+ dependents $62.00 $744.00 o Subscriber & 3+ dependents $80.75 $969.00

Last Name First Name M.I. Gender Marital Status Preferred Language

Address City State Zip Code Email Employer

Home Phone Work Phone Birth Date Requested Effective Date Dentist Number

ENROLLEES TO BE COVERED

Last Name First Name M.I. Gender Birth Date Relation to Subscriber

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

OFFICE USE

ONLY

1. Check or money order - annual payment

2. Checking withdrawal - automatic monthly payments*

3. Credit card - annual payment

4. Credit card - automatic monthly payments*

Visa MasterCard Discover

_______________________________________________________ Credit Card Number Expiration

_______________________________________________________ Amount (Annual or 2-months’ Premium) 3-Digit Code

_______________________________________________________ Signature Date

It is a crime to knowingly provide false, incomplete, or misleading information to a limited healthcare service contractor for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of benefits.

*Monthly payments require an initial 2-month payment, with the second month’s premium held by Dental Health Services, and used if automatic with-drawal is unavailable due to insufficient funds.

The account information on the enclosed check or listed credit card number is the account from which your premium payment will be withdrawn. Automatic checking withdrawal or monthly credit card charges begin the month following your eligibility date, and continue on or after the fifth of each month you are enrolled. By selecting payment option 2 or 4, you hereby authorize Den-tal Health Services to withdraw the applicable monthly payment from

SmartSmile Enrollment Formsm

Dependents include your spouse, domestic partner and/or children under 26 years of age. Children 26 years of age and over are eligible only while the child is and continues to be both 1) incapable of sustaining employment by reason of developmental disability or physical challenge, and 2) is chiefly dependent upon the subscriber for support and maintenance, provided proof of incapacity and dependency is furnished to Dental Health Services within 31 days of such a request but not more frequently than annually after the two-year period following the child’s attainment of 26 years of age.

Listed next to your dentist’s name in our Directory of Participating Dentists

your account. Monthly memberships renew automatically. Cancellation requests must be received in writing and must be signed by the primary subscriber. Cancellation requests received by the 15th of the current month will be effective the first of the following month.

By submitting this form I authorize my dentist to release any information re-garding my patient history to Dental Health Services, consulting professionals, or other designated or approved entities for the purpose of certifying, purchas-ing, providing, evaluating, or administering benefits. The authorization remains in effect until revoked by me in writing. I also certify that I am over 18 years of age. I agree that if I cancel my membership within the first year I will be subject to a $50.00 cancellation fee and will receive a pro-rated refund, if applicable.

Choose Your SmartSmilesm Plan

You can also enroll online at www.smartsmile.com

A M

Eff. Date Cycle Group# Plan# P/S# I.A.# Agent Name Agent#

Det

ach

the

com

ple

ted

form

and

mai

l or f

ax it

bac

k to

Den

tal H

ealth

Ser

vice

s.