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Changing Your Selected General Dental Office You or Your dependent may change Selected General Dental Offices at any time. To do so, please contact Us at (800) 880-1800. We will help You locate a convenient Selected General Dental Office. The transfer will be effective on the first day of the month following the transfer request. There is no limit to how often You or Your dependent may change Selected General Dental Offices. You must pay all outstanding charges owed to Your or Your dependent's Selected General Dental Office before transferring to a new Selected General Dental Office. You may also have to pay a fee for the cost of duplicating x-rays and dental records. Provider Reimbursement By statute, every contract between SafeGuard and its providers state that, in the event SafeGuard fails to pay the provider, You shall not be liable to the provider for any sums owed by SafeGuard. Selected General Dental Offices will collect all applicable co -payments from you directly at the time of service and then bill SafeGuard for reimbursement according to the contracted plan provisions. Selected General Dental Offices are paid on a per member, per month, or "capitated" basis for members that have selected the Selected General Dental Office and may receive an additional or supplemental fee for certain procedures performed. Specialty Care Dentists are compensated according to a negotiated fee schedule. No bonuses or incentives are paid to Selected General Dental Offices or Specialty Care Dentists. For additional information, you may contact SafeGuard at (800) 880-1800 or speak directly with Your provider. Liability of Subscriber or Enrollee for Payment Covered Services must be performed by Your Selected General Dental Office or a Specialty Care Dentist to whom You are referred in accordance with the terms of Your evidence of coverage and Schedule of Benefits. Services performed by any Out -of -Network Dentist are not Covered Services, without prior approval by SafeGuard or Your Selected General Dentist, in accordance with the terms of Your evidence of coverage and Schedule of Benefits (except for out -of -area emergency services). If You or Your dependent self -refer to a Selected General Dentist (other than Your or Your dependent's Selected General Dentist) or an Out -of - Network Dentist, You are responsible for the cost of those services. Prepayment Fee Your Organization prepays Us for Your and Your dependent's coverage. If You are responsible for any portion of this Prepayment Fee, Your Organization will advise You of the amount and how it is to be paid. Please refer to the Co -Payment section, below, for Information relating to Your Co -Payments under this group contract. The Prepayment Fee is not the same as a Co -Payment. The exact Prepayment Fee is contained in the group contract between Us and Your Organization. You may obtain a copy of the group contract from Your Organization, or by writing to SafeGuard Health Plans, Inc., Attn: Legal Department, 5 Park Plaza, Suite 1850, Irvine, CA 92614-2533, or by calling (800) 880-1800. Co -Payments When You or Your dependent receive care from either a Selected General Dentist or a Specialty Care Dentist, You must pay the Co -Payment. The Co -Payment is a fixed dollar amount or a fixed percentage of the Maximum Allowed Charge of the Covered Services performed by Your Selected General Dentist for which We are not responsible, as shown in the Schedule of Benefits. When You or Your dependent are referred to a Specialty Care Dentist, the Co -Payment may be either a fixed dollar amount, or a percentage of the Maximum Allowed Charge. Please refer to the Schedule of Benefits for specific details. When You have paid the required Co -Payment, if any, You have paid in full. If We fail to pay the Selected General Dentist, You will not be liable to the Selected General Dentist for any sums owed by Us. If You or Your dependent choose to receive services from an Out -of -Network Dentist, You will be liable to the Out -of -Network Dentist for the cost of services unless specifically authorized by Us or in accordance with Emergency Dental Condition provisions of this evidence of coverage. We do not require claim forms. GCERT2011-DHMO-EOC 2 5C_2 2