7/25/2019 Disenrollment Request CA_0116M014

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Disenrollment Request

IMPORTANT: Can you read this? If not, we can have somebody help you read it. You may also be able to get this information written in yourlanguage. For free help, please call right away at 1-866-756-4259. Dental Health Services has a toll free TTY line 1-888-645-1257 for the hearing andspeech impaired.

IMPORTANTE: Puede leer esta informacion? Si no, alguien le puede ayudar a leerla. Adems, es posible que reciba esta informacion escrita en supropio idioma. Para obtener ayuda gratuita, llame ahora mismo al 1-866-756-4259. Dental Health Services tambin tiene una lnea TTY 1-888-645-1257 para personas con difcultades de audicin o de hablar.

0116M014 2016 Dental Health Services

3833 Atlantic Avenue | Long Beach, CA 90807 | T 800-637-6453 | F 562-424-0150 | www.dentalhealthservices.com

Member Signature ______________________________________ Date __________________________

Please note that this form must be signed by the primary subscriber and faxed or mailed to us inorder to be effective.

Name _______________________________________ Member # _______________________________

Address ___________________________________________ City _______________________________

State _____________________ Zip Code ________________ Phone Number _____________________

Cancellation Policy

As stated in your Evidence of Coverage, if subscribers wish to cancel their plan prior to their firstyears renewal period, they will be subject to a $35 cancellation fee to cover the administrative andhealthcare costs of the cancellation process.

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 thefollowing month.

Is there anything we can do to make our plan more beneficial to you?

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* If your dentist is not currently participating with Dental Health Services, please call us at800-637-6453 and we can contact them to see if they are interested in joining our network.

** If the subscriber is deceased, please provide proof of death.

Other coverage No dentists in area Seeing a dentist not in the network*

Moved out of area Subscriber deceased** Financial reasons

No longer needed Other: _____________________________________________________

Please check the boxes for any reasons that apply to why you have decidedto cancel: