Page 5 - Golden Dental Plans – HealthChoice Welcome Dental Program
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PaymentInformationand EnrollmentForm•PleasePrint
Complete this form to secure the most affordable dental coverage available. By signing this form you are agreeing to a contract with Golden Dental Plans of Michigan Inc. for a period of 12 months.
You may cancel this contract within 72 hours after signing and receive a full refund.
PLAN
Single Double Family
MONTHLY
PAYMENT METHOD ENCLOSED:
Check Money Order
Visa MasterCard Discover
o $ 16.50 o $ 28.00 o $ 38.00
_________________________________________________________________________________________________ Credit Card Holder’s Name
_________________________________________________________________________________________________ Credit Card Number
_________________________________________________ ______________________________________________ Expiration Date CCV#
_________________________________________________________________________________________________ Signature
By signing this form I authorize payment on my credit card monthly, it will be billed prior to the effective date.
__________________________________________________________________________________________________ Name
___________________________________________________________ _____________________________________ Street Address City
________________________________________ _______________________________________________________ Telephone Number Email
__________________ __________________ ________________________________________________________ State Zip Code Group Name
Dependents: Spouse and children up to age 26 are eligible dependents.
Spouse ___________________________________ Children __________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________
Social Security No.
______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________
Sex
___________ ___________ ___________ ___________ ___________ ___________ ___________
Date of Birth
________________ ________________ ________________ ________________ ________________ ________________ ________________
Welcome Dental Program
____________________________________________________________________ ____________________________ Dental Office of Choice Office Facility Number
____________________________________________________________________ ____________________________ Signature Date
PLEASE COMPLETE THIS ENTIRE FORM AND RETURN TO:
HealthChoice of Michigan Welcome Dental Program 500 Griswold Street - 15th Floor, South Detroit, MI 48226
