Download Application

Where do I get an application form?

There are several ways to get an application:

  • Download and print the form off right now, mail to listed address.
  • Call us at (414) 259 -9522 and we will send you one.

DPPI Application (57 KB)

DENTAL SERVICES
CONTRACT NOTICE
REQUIREMENTS AND SUMMARY

SERVICES COVERED: The services covered by the Dental Protection Plan, Inc. (DPPI) plan are set forth in this Schedule.

EMERGENCY COVERAGE" Includes "EMERGENCY OR URGENT CARE" and means care needed for unforeseen dental illnesses, injuries or conditions which require immediate care.

OUT-OF-AREA COVERAGE: There is no coverage for out-of-area service.

DESIGNATED PROVIDERS: DESIGNATED PROVIDER means any Dentist designated by DPPI to perform services as your DESIGNATED PROVIDER under this Plan. The names of the DESIGNATED

PROVIDERS and the location of the offices where DESIGNATED PROVIDERS practice are set forth in the attached Schedule. The list of DESIGNATED PROVIDERS is subject to change upon periodic review by DPPI.

COST: The cost of the plan is $35.00 per year for individual coverage and $45.00 per year for family coverage when you have qualified dependents.

ENROLLMENT PROCEDURES: The enrollment procedures require you to submit a completed application and full payment of the appropriate fee to DPPI. After DPPI receives full payment of the Subscription fee and accepts your application you are considered to be enrolled. Coverage starts when DPPI approves your application.

BROKEN APPOINTMENTS: A fee, as filed with the commissioner of Insurance, will be charged for appointments broken when you fail to give your Provider a 24-hour notice.

EXCLUSIONS AND LIMITATIONS OF BENEFITS: Coverage is limited or excluded for the following"

  1. Dispensing of drugs is excluded.
  2. Hospital expenses are excluded.
  3. Experimental procedures are excluded.
  4. Is there a deductible benefit? No.
  5. General anesthesia and the services of anesthetists and anesthesiologists are excluded.
  6. Services your DPPI DESIGNATED PROVIDER does not recommend or deems unnecessary due to your general or dental health are excluded.
  7. Any care, including emergence or urgent care, not provided by a DPPI DESIGNATED PROVIDER within the geographical service area is excluded for care obtained from another DESIGNATED PROVIDER with the approval of the primary DESIGNATED PROVIDER.
  8. Services not specifically described in the schedule of benefits are excluded.
  9. Services necessitated as a result of declared or undeclared war or an act of war, a riot, insurrection or civil disturbance are excluded.
  10. Services or procedures performed after the last day of the month during which you were eligible for benefits from DPPI are excluded.
  11. Services costs and expenses incurred in the event you are hospitalized for dental procedures are excluded.
  12. Services usually and customarily treated by specialists when such services are not obtained from DPPI approved referral specialist DESIGNATED PROVIDERS are excluded.
  13. DPPI DESIGNATED PROVIDERS perform Emergency or Urgent Care only in their offices during regular office hours.
  14. Your payments, called co-payments, equal the amount not covered by DPPI or other Health Benefit Plans or HMO Plans.
  15. Benefits based upon a primary PPO or HMO fee schedule are excluded.

LIMITATIONS ON CHOICE OF PROVIDERS: Your choices of primary and referral providers is limited to those dentists who are listed by Dental Protection Plan, Inc. as DESIGNATED PROVIDERS. You may select a different Primary Provider upon a 30-day written notice to DPPI. DPPI may require you to select an alternate Primary Provider as provided under "TERMINATION, DISENROLLMENT AND FAILURE TO QUALIFY AS DEPENDENT." The same Primary Provider must be utilized by you and your dependents.

LIMITATIONS ON GEOGRAPHICAL AREA SERVED: Your dental services must be obtained in the locations delimited by the offices of dentists who are listed by Dental Protection Plan, Inc. as DESIGNATED

HOME  •   APPLICATION  •   FIND A PROVIDER  •   HOW YOU CAN BENEFIT  •   CONTACT US