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Como miembro de SafeGuard usted tiene derecho a recibir servicios gratultos de asistencia an idiomes, Esto incluye servicios de interpretaci6n y traducci6n, SafeGuard recaba Is information sobre sus preferenclas de Idioms, raze, y etnia de manera qua nos podamos comunicar eficazments con nuestros afiliados. Si necesita asistencia verbal o escrita an su idioma o qulere informarle a SafeGuard sobre su idioma de preferencla, comunrquese con nosotras al (800) 880.1 Boo. NOTICE FOR RESIDENTS OF ALL STATES Notice Regarding Your Rights and Responsibilities Bights: • During the term of the group contract between SafeGuard and Your Organization, SafeGuard will not decrease any benefits, increase any Co -Payment, or the Prepayment Fee, or change any exclusion or limitation, except after at least 30 days Written notice to Your Organization. • We will provide Written notice within a reasonable time to Your Organization of any termination or breach of contract by, or Inability to perform of, any contracting provider if Your Organization may be materially and adversely affected. • We will not cancel or fall to renew Your enrollment in this group contract because of your health condition or your requirements for dental cars. • We will treat communications, financial records and records pertaining to Your care in accordance with all applicable laws relating to privacy. • Decisions with respect to dental treatment are the responsibility of You and Your Selected General Dentist. We neither require nor prohibit any specified treatment. However. • Only certain specified services are Covered Services. Please see the Schedule of Benefits. Please also review the DENTAL BENEFITS section of this evidence of coverage for more details. • Your Selected General Dentist must follow the rules and limitations set up by SafeGuard and conduct his or her professional relationship with You within the guidelines established by SafeGuard. If SafeGuard's relationship with Your Selected General Dentist ends, Your Selected General Dentist must complete any and all treatment in progress, SafeGuard will arrange a transfer for You to another Selected General Dentist to provide for continued coverage under the group contract. As Indicated on Your enrollment form, Your signature authorizes SafeGuard to obtain copies of your dental records, if necessary. • You may request a response from SafeGuard to any Written concern or complaint. Responsibilities: • You should identify Yourself to Your Selected General Dentist as a covered person under the group contract. If You fail to do so, You may be charged the Selected General Dentist's usual and customary fees instead of the applicable Co -Payment, if any. • You should treat the Selected General Dentist and his or her office staff with respect and courtesy and cooperate with the prescribed course of treatment. If You continually refuse a prescribed course of treatment, Your Selected General Dentist or Specialty Care Dentist has the right to refuse to treat You. SafeGuard will facilitate second opinions and will permit You to change Your Selected General Dental Office; however, SafeGuard will not interfere with the dentist -patient relationship and cannot require a particular dentist to perform particular services. • You should contact the Selected General Dental Office twenty-four (24) hours in advance to cancel an appointment. If You do not, You may be charged a missed appointment fee. • You are responsible for the prompt payment of any charges for services performed by the Selected General Dentist. If the Selected General Dentist agrees to accept part of the payment directly from SafeGuard, You are responsible for prompt payment of the remaining part of the Selected General Dentist's charge. GCERT2011-DHMO-EOC 25C-19