Dental Plus of Oregon - Willamette Dental Group

You’re telling
me my teeth
can really last
a lifetime?
Dental Plus of Oregon
THE POLICY PROVIDES DENTAL BENEFITS ONLY.
Form No. 2121D-OR(12/15)
Agreement Form No. 2121-OR(7/12)
This discount dental plan is provided by Willamette Dental Insurance, Inc.
Personal care
for your individual needs
Willamette Dental Insurance, Inc. is pleased to
offer you Dental Plus of Oregon, a cost saving
dental discount plan. This plan gives you simple
access to quality dental care at a reduced fee.
Routine and preventive services are provided at
25% savings. Orthodontia is available for both
adults and children at a 15% reduction on usual
fees. Members do not need to fill out or submit
any claim forms.
As a member, you simply schedule your
appointments, see the dentist and pay charges at
that visit. Willamette Dental Group, P.C. dentists
make access to quality dental care easy, while
Dental Plus of Oregon keeps that care affordable
for you and your family.
Dental Plus of Oregon is not insurance. Plan members must pay for all dental and
ancillary services, but will receive a discount on eligible services from Willamette
Dental Group providers.
With more than 50 Locations
throughout the Pacific Northwest, we’re likely to have an
office in your neighborhood.
Oregon Locations
Washington
Oregon
Idaho
To receive discounted dental services, services must be received
from a Willamette Dental Group provider and all charges must
be paid in full at the time of the visit. Visa, Mastercard and
Discover are accepted. Membership must remain continuous
during the full treatment period to receive discounted services.
An advance appointment is required to receive care. To
schedule your dental appointments, call our Appointment
Center at 1.855.4DENTAL (433.6825), Option 1. When you speak
to a Willamette Dental Group representative or arrive at the
dental office for your appointment, simply identify yourself as a
Dental Plus of Oregon member. You will then receive discounts
on your quality dental care.
Most dental offices are open Monday through Friday, 7 AM to 6
PM, and occasional Saturdays.
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Albany
Beaverton
Beaverton Specialty
Bend
Corvallis
Eastport
Eugene
Gateway Specialty
Grants Pass
Gresham
Hillsboro
Lincoln City
Medford
Milwaukie
Portland – Westside
Roseburg
Salem – Lancaster
Salem – Liberty
S.E. Stark
Stark Specialty
Springfield
Tigard
Tillamook
Tualatin
Weidler
Discount Summary
Services must be received from a
Willamette Dental Group provider to
receive discounted services. Please
check with your Willamette Dental
Group, P.C. provider for charges on
specific treatment.
Annual
Membership Fees
Membership fees may be paid by
credit card, check or money order.
Single Membership
You will receive a 25% discount
on Willamette Dental Group general
dentist services, including:
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General exams
Cleanings
Fillings)
Crowns
You will receive a 15% discount on
Willamette Dental Group specialist or
denturist services, including:
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Orthodontia
Oral surgery
Pediatric dentistry
Periodontics (gum & bone
problems)
Endodontics (root canals)
Dentures
You will receive a 15% discount on
implant services.
For Appointments, please call:
1.855.4DENTAL (433.6825)
For Customer Service, please call:
503.952.2711
Willamette Dental Insurance, Inc.
6950 NE Campus Way, Hillsboro, OR 97124
Double Membership
Family Membership
$89.00
$178.00
$226.00
How To Enroll
To enroll in Dental Plus of Oregon, simply
complete the application form and submit
it along with payment of membership
fee. The application and membership fee
payment must be received by the 25th
of the month preceding the period
for which membership is to be
effective.
You must be at least 18 years of age
and a resident of Oregon. Eligible
family members include your legal
spouse or domestic partner and your
unmarried
dependent
children
through age 18 and through age 23 if
the child is a registered full-time
student
at
an
accredited
educational institution. You may
not be enrolled with Willamette
Dental insurance coverage.
If you would like additional
information please contact us at
503-952-2711 or visit us on the web at:
www.WillametteDental.com
www.WillametteDental.com
Willamette Dental - Dental Plus of Oregon Application Form
Willamette Dental Insurance, Inc.
6950 NE Campus Way, Hillsboro, Oregon 97124
Please print or type. Shaded areas are for producer
or office use only.
1
Account Number:
Effective Date:
I’m filling out this application because I am...
a new applicant applying for: (select box below)
Single membership
2
3
Double Membership
Family Membership
My information is...
Self (Last, First, Middle Initial)
Social Security Number
Gender
Mailing Address
City/State/Zip
Home Telephone Number
E-mail Address
Date of Birth
Requested Effective Date
F
My premium payment will be paid by...
Personal Check
Money Order
Credit Card (Visa, MC, Discover)
Credit Card Number:
Expiration Date:
CDC (3 digit security code):
Signature:
4
M
Date:
I want to enroll my...
Legal Spouse or Domestic Partner (Last, First,
Middle Initial)
Date of Birth
Gender
Date of Birth
F
Husband/Wife
Domestic Partner
Social Security Number
Dependent Child (Last, First, Middle Initial)
M
Gender
M
F
M
F
M
F
Social Security Number
Dependent Child (Last, First, Middle Initial)
Date of Birth
Gender
Social Security Number
Dependent Child (Last, First, Middle Initial)
Date of Birth
Gender
Social Security Number
Pay Commissions To:
 Producer
 Agency
Producer or Agency Address:
Form No. 2121C-OR(7/12)
Producer or Agency Name:
Producer or Agency Phone Number:
Please continue application on back...
Agreement
I hereby apply for membership in the discount dental plan, Dental Plus of Oregon, offered
through Willamette Dental Insurance, Inc. for myself and all listed family members. I
acknowledge that Willamette Dental Group reserves the right to change membership fees
and provisions of the Membership Agreement. I understand that payment of membership
fees shall be deemed acceptance of the terms of Membership Agreement. I agree to advise
Willamette Dental Group of any change in status within 30 days from the date of change. To
the best of my knowledge, the information I have provided in this application form is true and
complete. If I choose to sign this application by typing my name below, I acknowledge and
agree that my typewritten signature has the same legal effect as my written signature on this
application.
Applicant’s signature: _______________________________________________________
Date: _______________________
Mail this completed application and your membership payment to:
Willamette Dental Insurance, Inc.
Dental Plus of Oregon
6950 NE Campus Way
Hillsboro, OR 97124
You can also email or fax your completed application to:
[email protected] or 503-952-2679.
Make checks payable to: Willamette Dental Insurance, Inc.
Summary of Exclusions
The following services are not eligible for a discount through this plan: Services
provided by a provider other than a Willamette Dental Group provider. | Services
received before the effective date, prior to cancellation for a full refund, or after the
termination of membership. | General anesthesia, including conscious, intravenous
and moderate sedation | Hospitalization charges | Dental treatment not performed in
a Willamette Dental Group office. | Cosmetic dentistry. | Dental treatment which your
Willamette Dental Group provider determines to be unnecessary. | Charges by any
person other than a licensed dentist, licensed denturist, or licensed hygienist. | This
plan does not coordinate benefits.
Please refer to your agreement for a complete description of terms, conditions and
exclusions.
www.WillametteDental.com