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NOTICE FOR RESIDENTS OF CALIFORNIA This evidence of coverage provides a detailed summary of how your SafeGuard dental contract operates, Your entitlements, and the contract's restrictions and limitations. This combined evidence of coverage and disclosure statement constitutes only a summary of the contract. The contract must be consulted to determine the exact terms and conditions of coverage. If You have special health care needs, You should read carefully those sections that apply to You. You may obtain a copy of the contract by requesting it from the 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, This evidence of coverage and disclosure statement is subject to Chapter 2.2 of Division 2 of the California Health and Safety Code (commonly referred to as the Knox -Keene Act) and the regulations Issued thereto by the Department of Managed Health Care, Should either the law or the regulations be amended, such amendments shall automatically be deemed to be a part of this document and shall take precedence over any inconsistent provision of this contract. Any provision required to be in this evidence of coverage and disclosure statement by either law or the regulation shall automatically bind SafeGuard. Pursuant to Section 1365(b) of the Knox -Keene Health Care Service Plan Act of 1975, as amended, an enrollee or subscriber who alleges that his or her enrollment has been canceled or not renewed because of his or her health status or requirements for health care services may request a review by the Director of California Department of Managed Health Care. If the Director determines that a proper complaint exists, the Director shall notify SafeGuard, Within 16 days after receipt of such notice, SafeGuard shall either request a hearing or reinstate the enrollee or subscriber. If, after hearing, the Director determines that the cancellation or failure to renew is improper, the Director shall order SafeGuard to reinstate the enrollee or subscriber. A reinstatement pursuant to this provision shall be retroactive to the time of cancellation or failure to renew and SafeGuard shall be liable for the expenses incurred by the subscriber or enrollee for covered health care services from the date of cancellation or non -renewal to and including the date or reinstatement. Confidentiality of Dental Records A STATEMENT DESCRIBING SAFEGUARD'S POLICIES AND PROCEDURES FOR PRESERVING THE CONFIDENTIALITY OF DENTAL RECORDS IS AVAILABLE AND WILL BE FURNISHED TO YOU UPON REQUEST. Organ Donation Donating organs and tissues provides many societal benefits. Organ and tissue donation allows recipients of transplants to go on to lead fuller and more meaningful lives, Currently, the need for organ transplants far exceeds availability. If You are Interested in organ donation, please speak with Your physician. Organ donation begins at the hospital when a person is pronounced brain dead and Is Identified as a potential organ donor. An organ procurement group will become Involved to coordinate the activities, Language Assistance As a SafeGuard Member You have a right to free language assistance services, including Interpretation and translation services. SafeGuard collects and maintains Your language preferences, race, and ethnicity so that we can communicate more effectively with our Members. If You require spoken or Written language assistance or would like to Inform SafeGuard of Your preferred language, please contact us at (800) 680- 1800, fV%SafaGuard0*A, fes; t 1 # WMIT09ifil. SafeQu8rdl&fflWA11*ri I Ol`! NSON, %in t" NS 't � M ISM, a s i # A�1 Safedttard, f 9 ft i Safe uardll if , Wit 0(800) seem1840, GCERT2011-DHMO-EOC 2 6l