The Premier Choi e i De tal & Visio Be efits

Transcription

1 The Premier Choi e i De tal & Visio Be efits Mee Guide Fo G oups F eedo Pla Toll F ee - - West State St eet Ta pa, Flo ida A gus De tal & Visio, I., a Flo ida o po atio, is a P epaid Li ited Health Sei es O ga izatio li e sed u de Flo ida Statutes, Chapte. The pla ee is o ligated to pa fo all health a e sei es a d ill e ei e a dis ou t f o the p o ide s ho pa ti ipate i the et o k.

2 Welcome to Argus Dental & Vision! Tha k ou fo hoosi g A gus De tal & Visio as ou health a e pa t e. The A gus tea o ks a efull to deli e supe io e efits that a e desig ed ith ou ee s i i d a d to p o ide ou the est optio s ased o ou spe ifi eeds. Ou suppo t s ste s ha e ee de eloped to deli e the ualit ou e ui e a d e pe t f o ou e efits e pe ts. As ou a igate th ough ou e e efits, e hope ou ll fi d the i foatio i this guide helpful. We pla e high p io it o aki g e tai ou ha e a supe io usto e e pe iee e e ti e ou e gage ou o pa. Ou tea of k o ledgea le sei e p ofessio als is eage to assist ou ith a uestio s o o - es. We e og ize ou ha e a othe hoi es. Tha k ou fo pa t e i g ith A gus De tal & Visio. We look foa d to eai g ou t ust a d o fidee to ai tai a ea s of sei e to ou fo ou de tal a d isio a e. Best Rega ds, Ni holas M. Ka ouklis, DMD CEO & P eside t

3 F e ue tl Asked Questio s What is the e efit of pa ti ipati g i the F eedo Pla? The F eedo Pla p o ides full o e age o a ious p e e ti e a e de tal sei es. F eedo Pla ee s a hoose a de tist of thei hoi e. If a Net o k De tist is hose, ee s ill ge e all iu less out-of-po ket osts. I additio, ou a e e titled to e ei e u e ous othe de tal a e sei es ide tified i the S hedule of Be efits i eha ge fo the appli a le o-pae t ide tified i the S hedule of Be efits. What de tal sei es a e a aila le u de the F eedo Pla? The S hedule of Be efits set fo th i this F eedo Pla Mee Guide ide tifies the u e ous o e ed sei es a aila le u de the F eedo Pla, as ell as the Co pae ts appli a le to ea h su h sei e. What if a pa ti ula de tal sei e is ot listed i the S hedule of Be efits? Ge e all, de tal sei es that a e ot listed i the S hedule of Be efits a e a aila le at a % dis ou t off of the Net- o k De tist s oal/ usto a ha ge. If seeki g sei es f o a No -Net o k De tist, the o - o e ed p o edu es ill e the ee s espo si ilit. Additio all, the e a e so e de tal sei es that a e ot su je t to a dis ou t a d a e ot otheise a aila le u de the F eedo Pla. Please efe to the Li itatio s a d Elusio s se tio of the S hedule of Be efits. Do I eed to o tai a p e-autho izatio fo a de tal p o edu es? The F eedo Pla does e ui e p e-autho izatio p io to e ei i g sei es fo su gi al e t a tio s a d os. Ho do I sele t a Net o k De tist? You a isit.a gusde tal isio. o ou e site to fi d a Net o k De tist i ou a ea, o ou a o ta t A gus Custo e Ca e at.... Ho do I ha ge add ess o o ta t i foatio? To update ou add ess o o ta t i foatio, please o ta t A gus Custo e Ca e at.... Who do I o ta t if I ha e uestio s ega di g the F eedo Pla? Please o ta t A gus Custo e Ca e at.... Ho do I ake a de tal appoi t e t? To ake a appoi t e t, si pl o ta t the De tist that ou ha e sele ted. Whe ou all the de tist s off e, ou should ide tif ou self as a A gus F eedo Pla ee, a d p o ide the de tist s off e ith ou effe ti e date of o e age a d the ue o ou F eedo Pla ID a d. Be su e to p ese t ou A gus F eedo Pla ID a d oe ou ai e at ou s heduled appoi t e t. You ill also e e ui ed to p ese t a photo ide tifi atio a d at ea h appoi t- e t.

4 What if I eed spe ialt a e? You ha e aess to spe ialist i all fields of de tist at edu ed ates th ough ou F eedo Pla. A gus e oe ds that ou isit ou Net o k De tist fo a app op iate diag osis p io to isiti g a spe ialist. If ou e ei e de tal a e f o a Net o k De tist, the o-pae ts ide tified i the S hedule of Be efits appl. Ho u h ill ost e he usi g a No -Net o k De tist? If ou e ei e de tal a e f o a Net o k De tist, the o-pae ts ide tified i the S hedule of Be efits appl. If ou e ei e de tal a e f o a No -Net o k De tist ou ill e espo si le fo ou opae t a d a additio al fees up to the de tists usual a d usto a ha ges, less A gus pae t, i ao dae ith the S hedule of Be efits. What if I ha e a De tal E e ge? Befo e a De tal E e ge a ises, please o ta t ou Net o k De tist to fi d out ho he o she should e o ta ted if ou eed u ge t a e t eat e t o t eat e t afte oal off e hou s. Ou Net o k De tists ha e thei o pla fo ho the a e ea hed i ase of e e ge, o the ill ake p io aa ge e ts ith othe de tists if the a e u a aila le to p o ide a e to ou i ase ou eed t eat e t iediatel o u ge tl. If ou ha e a De tal E e ge, please o ta t ou Net o k De tist o A gus Custo e Ca e at.... If ou e e ge ou s afte egula usi ess hou s, please o ta t ou Net o k De tist. If ou a e u a le to ea h ou Net o k De tist, please all. De tal E e ge sei es ill e o e ed u de the F eedo Pla if the sei es a e ide tified i the S hedule of Be efits. Does A gus ha dle oo di atio of e efits? No A gus does ot ha dle oo di atio of e efits fo F eedo Pla ee s. Defi itio s Appli a le to the F eedo Pla : Co pae t ea s the pae t o ed the Mee to the Net o k De tist fo the Co e ed Sei e e de ed. Co e ed Sei es ea s the sei es a d t eat e t that a e pa a le o a aila le u de the F eedo Pla. De tal E e ge ea s the sudde a d u e pe ted o set of a a ute o ditio iol i g se e e pai, e- ui i g iediate de tal a e fo te po a elief of pai a d suffe i g. E a ples of De tal E e geies i - lude a tootha he a d o al t au a. Mee ea s a i di idual e titled to e ei e Co e ed Sei es u de the F eedo Pla. Net o k De tist ea s a de tal a e p a titio e o fa ilit ho/ hi h has e te ed i to a ag ee e t ith A gus fo the p o isio of Co e ed Sei es u de the F eedo Pla. P e iu ea s the pe iodi o thl o aual pae t o ed to A gus i eha ge fo pa ti ipatio i a d o e age u de the F eedo Pla. S hedule of Be efits efe s to the s hedule set fo th elo hi h outli es a the Co e ed Sei es la eled u de the F eedo Pla, the appli a le Co pae t pa a le the Mee to the Net o k De tist fo ea h Co e ed Sei e, a d the othe tes a d o ditio s appli a le to the F eedo Pla.

5 Mee Co e age You o e age u de the F eedo Pla ill e effe ti e o the fi st da of the o th follo i g ou fi st p e- iu pae t. Mee ship fee s, pae ts a d othe tes a d o ditio s of the Pla a e ha ged. A gus ag ees to otif Mee s, i iti g, of the atu e a d e te t of su h ha ges fo t -fi e da s p io to the effe ti e date of su h ha ges. Mo thl P e iu. I eha ge fo ou pa ti ipatio i the F eedo Pla, ou ill e e ui ed to pa a o thl p e- iu fee to A gus as follo s: MONTHLY* ANNUAL I di idual $. $. I di idual +Spouse $. $. I di idual + Child $. $. Fa il $. $. * Fo o thl p e iu s, ou aou t ill e de ited o ha ged the o thl p e iu stated plus a $ o thl sei e ha ge. Due Date. You o thl P e iu is due o late tha the fiftee th th da of ea h o th. Ho e e, ou ill ha e a te da g a e pe iod to ake ou pae t. This ea s that if a e ui ed p e iu is ot paid to A gus o o efo e the date it is due, it a e paid du i g the g a e pe iod a d ou o e age ill sta i foe du i g that ti e. O goi g Ca e. If A gus tei ates ou pa ti ipatio i the F eedo Pla i ao dae ith the tes set fo th i the Eoll e t Appli atio, su h tei atio ill e ithout p ejudi e to a o ti uous loss that ega hile ou o e age as i foe. I the ase of a su h o ti uous loss, A gus shall o ti ue to p o ide its sei es he eu de, a d shall e ui e the Net o k De tists to o ti ue to p o ide thei sei es u til the ea lie of a the date the spe ifi t eat e t o p o edu e has ee o pleted, o i et da s f o the tei atio date of ou pa ti ipatio. Ho e e, this ill o l e the ase if ou o ti ue to pa the o thl p e iu o ed du i g su h ti e. Eligi ilit Eoll e t. I additio to ou self, ou a eoll ou eligi le fa il ee s i the F eedo Pla. You eligi- le fa il ee s ilude ou spouse o do esti pa t e a d ou atu al o a d adopted hild e iludi g a hild e pla ed ith ou fo adoptio ho ha e ot et attai ed age t e t si o a e su sta tiall depe de t o ou fo suppo t a d ai te ae a d iapa le of sustai i g e ploe t easo of e tal o ph si al disa ilit. Eoll e t of Ne l Eligi le Pe so s. You a eoll ou eo hild i the F eedo Pla f o the o e t of i th, adoptio, o pla e e t fo adoptio of su h hild. You a also eoll a e l eligi le fa il ee i the F eedo Pla. Ho e e, ou ust do so ithi thi t da s of the date he/she eets the eligi ilit e ui e e ts of the F eedo Pla. Notifi atio O ligatio. You ust otif A gus if ou aui e a e fa il ee o if a fa il ee loses eligi ilit to pa ti ipate i the F eedo Pla. You ust p o ide this i foatio ithi fiftee da s of the date of the appli a- le ha ge. P i a. A gus ag ees to o pl ith all fede al a d state la s that p ote t the p i a a d se u it of pe so al health i foatio.

6 Possi le Auto ati Tei atio. You pa ti ipatio i the F eedo Pla ill auto ati all tei ate if the Flo ida Off e of I su ae Regulatio issues a o de e ui i g aellatio of ou pa ti ipatio, a d su h o de e o es fi al a d o appeala le. A gus Caellatio Rights. A gus is e titled to ael ou pa ti ipatio o the pa ti ipatio of a of ou fa il ee s, upo fo t fi e da s itte oti e if: a You eha io is dis upti e, uul, a usi e, u la ful, f audule t, o uoope ati e to the e te t that ou o ti ui g pa ti ipatio se iousl i pai s A gus a ilit to p o ide sei es to othe Mee s You e gage i f aud o ake a ate ial is ep ese tatio i appl i g fo o p ese ti g a lai fo e efits You isuse do u e ts p o ided as e idee of e efits a aila le u de the F eedo Pla, o d You p o ide A gus ith ioe t o io plete i foatio fo the pu poses of f audule tl o tai i g sei es o e efits. P io to aelli g ou pa ti ipatio as p o ided a o e, A gus ust ake a effo t to esol e the p o le th ough its g ie ae p o edu es, a d ust detei e that ou eha io is ot due to use of the sei es p o ided o e tal ill- ess. Eused Pe foae. A gus shall ot e lia le to ou o a othe Mee fo a failu e o dela i pe foi g its o ligatio s, hi h dela o failu e is due, i hole o i pa t, di e tl o i di e tl, to a o ti ge, dela, failu e, o ause of a atu e e o d the easo a le o t ol of A gus, iludi g, ithout li itatio, fi e, e plosio, ea th uake, sto, flood o othe eathe elated e e t o a a t of God; u a aila ilit of e essa utilities, o po e ts, o a ate ials; st ike, lo kout o a ti ities of a oi atio of o k e o othe la o diff ulties; a, a t of teo is, i sue tio o iot; appli atio of a la, a t, o de, e po t o t ol egulatio, p o la atio, deee, egulatio, o di ae, o i st u tio s of go e e t o othe pu li autho ities, o a judg e t o deee of a ou t of o pete t ju isdi tio ot a isi g out of a ea h of its o ligatio s he eu de. I the e e t of the happe i g of su h a ause, A gus shall p o ide ou ith p o pt, itte oti e stati g the pe iod of ti e the failu e to pe fo is e pe ted to o ti ue, a d shall esu e its pe foae as soo as easo a l possi le. No Right of Assige t. Neithe ou o a of ou fa il ee s shall ha e the ight to assig, delegate, o othe - ise t a sfe a o all of ou ights a d/o o ligatio s elati g to the F eedo Pla to a thi d pa t. E ti e Ag ee e t. The Eoll e t Appli atio, Ce tifi ate, a d Mee Guide set fo th the e ti e ag ee e t et ee ou a d A gus elati g to the F eedo Pla. U less otheise stated, the tes of ou ag ee e t a ot e a e ded o odified u less the a e d e t o odifi atio is i iti g a d is sig ed ou a d A gus. As stated a o e, A gus ill otif Mee s, i iti g, of the atu e a d e te t of a a e d e t o odifi atio fo t -fi e da s p io to the effe ti e date of su h ha ges. Wai e. No ai e of a ea h o o ditio of ou ag ee e t ith A gus shall e o side ed a ai e of a su se- ue t ea h o o ditio, hethe of like o diffe e t atu e. Go ei g La. You ag ee e t ith A gus ill e go eed the la s of the State of Flo ida. Ju isdi tio a d Ve ue; Fees. Ait atio is olu ta a d shall e o du ted pu sua t to Flo ida Statutes Chapte. A ait atio, ediatio o a tio to e foe o i te p et the ights of the pa ties ith espe t to the F eedo Pla shall e hea d solel a d elusi el i Hills o ough Cou t, Flo ida. You he e o se t, o ehalf of ou self a d ou fa il ee s, to su h elusi e ju isdi tio a d e ue. You ill e espo si le fo pa i g ou o legal fees i a su h elusi e ju isdi tio a d e ue. You ill e espo si le fo pa i g ou o legal fees i a su h ait atio, ediatio o a tio.

7 S hedule of Be efits: The elo o-pae ts o tai ed i this fee s hedule a e alid he t eat e t is p o ided a Pa ti ipati g De tist. If the se - i es of a No -Pa ti ipati g De tist a e e oe ded a d a aila le, a d a e a o e ed e efit, the the elo o-pae ts appl a d the ee ill pa the diffe ee up to the de tist's oal illed ha ge. If the sei es fo o - o e ed p o edu es a e pe foed a No -Pa ti ipati g De tist the ha ge ill e patie t espo si ilit. If a sei e is ot listed elo, it a e a aila le at the Pa ti ipati g De tal P o ide 's Usual a d Custo a Fee, less a dis- ou t of %. Ea h off e isit iludes all fees fo ste ilizatio a d i fe tio o t ol. Code DIAGNOSTICS Procedure Description Limitations/ Pre-Authorizations Member Pays D Pe iodi O al E aluatio - Esta lished Patie t of D, D o D e e o ths D Li ited O al E aluatio - P o. Fo used of D, D o D e e o ths D O al E aluatio fo a Patie t u de th ee ea s of age a d ou seli g ith p i a a egi e NA D Co p ehe si e O al E a of D, D o D e e o ths D Detailed a d E te si e O al E aluatio - P o le Fo used, Repo t NA D Co p ehe si e Pe iodo tal E aluatio NA D X- a s I t ao al - Co plete Se ies I. Bite i gs pe ea s D X- a s I t ao al - Pe iapi al - Fi st Fil pe ea D X- a s I t ao al - Pe iapi al - Ea h Additio al Fil pe ea D X- a s I t ao al - Olusal Fil NA D E t ao al - Fi st Fil NA D E t ao al - Ea h Additio al Fil NA D X- a s Bite i g - Si gle Fil pe ea D X- a s Bite i gs - T o Fil s pe ea D X- a s Bite i gs - Th ee Fil s pe ea D X- a s Bite i gs - Fou Fil s pe ea D Ve ti al Bite i gs - to Fil s NA D Poste io - A te io o Late al Skull a d Fa ial Bo e Sue Fil NA D Te po o a di ula joi t fil NA D To og aphi Sue NA D X- a s Pa o a i Fil pe ea s D Cephalo et i fil NA D O al/fa ial photog aphi i ages NA D Pulp Vitalit Testi g NA D Diag osti Casts NA PREVENTIVES D P oph la is - Adult pe o ths D P oph la is - Child pe o ths D Topi al Fluo ide Vaish; the apeuti appli atio fo ode ate to high a ies isk patie ts NA D Topi al Appli atio of Fluo ide NA D Nut itio al Cou seli g fo Co t ol of De tal Disease NA D To ao Cou seli g NA D O al H gie e I st u tio NA D Seala t - Pe Tooth NA D Spa e Mai tai e - Fi ed - U ilate al NA D Spa e Mai tai e - Fi ed - Bilate al NA D Spa e Mai tai e - Re o a le - U ilate al NA D Spa e Mai tai e - Re o a le - Bilate al NA D Re e e tatio of Spa e Mai tai e NA D Re o al of Fi ed Spa e Mai tai e NA

8 Code Procedure Description Limitations/ Pre-Authorizations Member Pays RESTORATIVES D A alga - O e Su fa e, P i a o Pea e t D A alga - T o Su fa es, P i a o Pea e t D A alga - Th ee Su fa es, P i a o Pea e t D A alga - Fou o Mo e Su fa es, P i a o Pea e t D Resi - O e Su fa e, A te io D Resi - T o Su fa es, A te io -,, o su fa e a alga o esi D Resi - Th ee Su fa es, A te io esto atio s pe ea D Resi - Fou o Mo e Su fa es, A te io o Iol i g Iisal A gle D Resi -Based Co posite C o, A te io D Resi -Based Co posite, O e Su fa e, Poste io D Resi -Based Co posite, T o Su fa es, Poste io D Resi -Based Co posite, Th ee Su fa es, Poste io D Resi -Based Co posite, Fou Su fa es, Poste io D Gold Foil - O e Su fa e NA D Gold Foil - T o Su fa es NA D Gold Foil - Th ee Su fa es NA D I la - Metalli - O e Su fa e NA D I la - Metalli - T o Su fa es NA D I la - Metalli - Th ee o Mo e Su fa es NA D O la - Metalli - Th ee Su fa es NA D O la - Metalli - Fou o Mo e Su fa es NA D I la - Poelai /Ce a i - O e Su fa e NA D I la - Poelai /Ce a i - T o Su fa es NA D I la - Poelai /Ce a i - Th ee o Mo e Su fa e NA D O la - Poelai /Ce a i - T o Su fa es NA D O la - Poelai /Ce a i - Th ee Su fa es NA D O la - Poelai /Ce a i - Fou o Mo e Su fa es NA D I la - Resi -Based Co posite - O e Su fa e NA D I la - Resi -Based Co posite - T o Su fa es NA D I la - Resi -Based Co posite - Th ee o Mo e Su fa es NA D O la - Resi -Based Co posite - T o Su fa es NA D O la - Resi -Based Co posite - Th ee Su fa es NA D O la - Resi -Based Co posite - Fou o Mo e Su fa es NA D C o - Resi -Based Co posite I di e t * D C o - Resi ith High No le Metal* D C o - Resi ith P edo i a tl Base Metal* D D D C o - Resi ith No le Metal* C o Poelai /Ce a i Su st ate* C o Poelai Fused to High No le Metal * of D, D, D, D, D, D, D, D, D, D, D, D, D, D o D pe ea D C o Poelai Fused to P edo i atel Base Metal* D C o Poelai Fused to No le Metal* D C o - / Cast High No le Metal* D C o - / Cast P edo i a tl Base Metal* *P e-autho izatio e ui ed; suppo ti g do u- D C o - / Cast No le Metal* e tatio e ui ed P e-ope ati e X- as, Post- Ope ati e X as D C o - / Poelai /Ce a i * D C o - Full Cast High No le Metal* D C o - Full Cast P edo i atel Base Metal* D C o - Full Cast No le Metal*

9 Code Procedure Description Limitations/ Pre-Authorizations RESTORATIVES D Re e e t I la, O la, o Pa tial o e age esto atio NA D Re e e t ast o p efai ated post a d o e NA D Re e e t C o NA D P efai ated Stai less Steel C o - P i a NA D P efai ated Stai less Steel C o - Pea e t NA D P efai ated Resi C o NA D P efai ated Stai less Steel C o ith Resi Wi do NA D P ote ti e Resto atio Sedati e Filli g NA D Co e Buildup, Il. A Pi s NA D Pi Rete tio - Pe Tooth, i Additio to Resto atio NA D Post a d Co e i Additio to C o, I di e tl Fai ated NA D Ea h Additio al I di e tl Fai ated Post - Sa e Tooth NA D P efai ated E do Post a d Co e i Additio to C o NA D Post Re o al Not i Co jutio ith E dodo ti The ap NA D Ea h Additio al P efai ated Post - Sa e Tooth NA D La ial e ee esi la i ate - hai side NA D La ial e ee esi la i ate - la o ato NA D La ial e ee poelai la i ate - la o ato NA D Te po a C o f a tu ed tooth, if sepa ate f o C o NA ENDODONTICS D Pulp Cap, Di e t El. Fi al Resto atio NA D Pulp Cap, I di e t El. Fi al Resto atio NA D The apeuti Pulpoto NA D Pulpal Deide e t, P i a a d Pea e t Teeth NA D Pulpal The ap Resoa le Filli g - A te io, P i a Tooth Eludi g Fi al Resto atio NA D Pulpal The ap Resoa le Filli g - Poste io, P i a Tooth Eludi g Fi al Resto atio NA D Root Ca al - A te io - Pe Tooth NA D Root Ca al - Bi uspid - Pe Tooth NA D Root Ca al - Mola - Pe Tooth NA Member Pays D Io plete e dodo ti the ap ; i ope a le, uesto a le o f a tu ed tooth NA D Ret eat e t of P e ious Root Ca al The ap - A te io NA D Ret eat e t of P e ious Root Ca al The ap - Bi uspid NA D Ret eat e t of P e ious Root Ca al The ap - Mola NA D Ape ifi atio / e al ifi atio - I itial Visit NA D Ape ifi atio / e al ifi atio - I te i edi atio epla e e t api al losu e/ al ifi epai of pe fo atio s, oot eso ptio, et. NA D Ape ifi atio / e al ifi atio - Fi al Visit iludes o pleted oot a al the ap - api al losu e/ al ifi epai of pe fo atio s, oot eso ptio, et NA D Api oe to/pe i adi ula Su ge - A te io NA D Api oe to/pe i adi ula Su ge - Bi uspid, Fi st Root NA D Api oe to/pe i adi ula Su ge - Mola, Fi st Root NA D Api oe to/pe i adi ula Su ge - Additio al Roots NA D Ret og ade Filli g NA D Root A putatio - Pe Root NA D E dodo ti e dosseous i pla t NA D I te tio al Rei pla tatio Iludi g Ne essa Spli ti g NA D Su gi al P o edu e fo Isolatio of Tooth ith Rue Da NA D He ise tio - Iludi g Root Re o al Eludi g Root Ca al The ap NA D Ca al p epa atio a d fitt g of p efoed post NA

10 Code PERIODONTICS Procedure Description Limitations/ Pre-Authorizations Member Pays D Gi gi e to o Gi gi oplast - Pe Quad o Mo e Teeth NA D Gi gi e to o Gi gi oplast, Pe Quad to Teeth NA D Gi gi al Flap P o edu e Il. Root plai g - o Mo e Teeth Pe Quad a t NA D Gi gi al Flap P o edu e Il. Root plai g - to Teeth Pe Quad a t NA D Api all positio ed flap NA D Cli i al C o Le gthe i g - Ha d Tissue NA D Osseous Su ge Iludi g Flap E t a d Closu e -Pe Quad. o Mo e Teeth NA D Osseous Su ge Iludi g Flap E t a d Closu e - Pe Quad. to Teeth NA D Bo e epla e e t g aft - fi st site i uad a t NA D Bo e Repla e e t G aft - Ea h Additio al Site i Quad a t NA D Guided Tissue Rege e atio - Resoa le Baie, pe site NA Guided Tissue Rege e atio - Noesoa le Baie, pe site iludes e a e D e o al NA D Pedi le Soft Tissue G aft P o edu e NA D F ee Soft Tissue G aft P o edu e Il. Do o Site Su ge NA Distal o Po i al Wedge P o edu e he ot pe foed i o jutio ith su gi- D al p o edu es i the sa e a ato i al a ea NA D P o isio al Spli ti g - i t a o o al NA D P o isio al Spli ti g - e t a o o al NA D Pe iodo tal S ali g a d Root Plai g - Pe Quad. o Mo e Teeth of D o D pe o ths pe uad a t. Not allo ed o the Pe iodo tal S ali g a d Root Plai g - Pe Quad. to Teeth D sa e date as D o D D Full Mouth Deide e t to E a le Co p ehe si e E aluatio & Diag osis NA Pe iodo tal Mai te ae P o edu es - Follo i g A ti e Su ge i a Mo th D Pe iod pe o ths D U s heduled D essi g Cha ge so eo e the tha t eati g de tist NA PROSTHODONTICS D Co plete Uppe De tu e NA D Co plete Lo e De tu e NA D Iediate Uppe De tu e NA D Iediate Lo e De tu e NA D Pa tial Uppe - Resi Base ith Clasps/Rests & Teeth NA D Pa tial Lo e - Resi Base ith Clasps/Rests & Teeth NA D Uppe Pa tial - Cast Metal Base ith Resi Saddles / Clasps/Rests & Teeth NA D Lo e Pa tial - Cast Metal Base ith Resi Saddles / Clasps/Rests & Teeth NA D Re o a le U ilate al Pa tial De tu e - O e Pie e Cast Metal iludi g lasps a d teeth NA D Adjust Co plete De tu e - Uppe NA D Adjust Co plete De tu e - Lo e NA D Adjust Pa tial De tu e - Uppe NA D Adjust Pa tial De tu e - Lo e NA D Repai B oke Co plete De tu e Base NA D Repla e Missi g o B oke Teeth NA D Repai Resi De tu e Base NA D Repai Cast F a e o k NA D Repai o Repla e B oke Clasp NA D Repla e B oke Teeth - Pe Tooth NA D Add Tooth to E isti g Pa tial De tu e NA D Add Clasp to E isti g Pa tial De tu e NA

11 Code PROSTHODONTICS Procedure Description Limitations/ Pre-Authorizations Member Pays D Re ase Co plete Ma illa De tu e NA D Re ase Co plete Ma di ula De tu e NA D Re ase Ma illa Pa tial De tu e NA D Re ase Ma di ula Pa tial De tu e NA D Chai side Reli e Co plete Uppe De tu e NA D Chai side Reli e Co plete Lo e De tu e NA D Chai side Reli e Uppe Pa tial NA D Chai side Reli e Lo e Pa tial NA D La o ato Reli e Co plete Uppe De tu e NA D La o ato Reli e Co plete Lo e De tu e NA D La o ato Reli e Uppe Pa tial NA D La o ato Reli e Lo e Pa tial NA D I te i Co plete De tu e Ma illa NA D I te i Co plete De tu e Ma di ula NA D I te i Pa tial De tu e Ma illa NA D I te i Pa tial De tu e Ma di ula NA D Tissue Co ditio i g Ma illa NA D Tissue Co ditio i g Ma di ula NA D O e de tu e o plete NA D O e de tu e pa tial NA D Fluo ide Gel Caie NA D Coissu e Spli t NA PROSTHODONTICS-FIXED D Su gi al Pla e e t of I pla t Bod : E dosteal I pla t NA D Su gi al Pla e e t: Eposteal I pla t NA D Su gi al Pla e e t: T a sosteal I pla t NA D De tal I pla t Suppo ted Coe ti g Ba NA I pla t Mai te ae P o edu es, Iludi g Re o al of P osthesis, Clea si g of P osthesis a d D A ut e ts a d Rei se tio of P osthesis NA D Po ti - Cast High No le Metal NA D Po ti - Cast P edo i a tl Base Metal NA D Po ti - Cast No le Metal NA D Po ti - Tita iu NA D Po ti - Poelai Fused to High No le Metal NA D Po ti - Poelai Fused to P edo i a tl Base Metal NA D Po ti - Poelai Fused to No le Metal NA D Po ti - Resi ith high o le etal NA D Po ti - Resi ith p edo i a tl ase etal NA D Po ti - Resi ith o el etal NA D Cast etal etai e fo a id et h idge NA D C o - Resi ith high o le etal NA D C o - Resi ith p edo i a tl ase etal NA

12 Code PROSTHODONTICS-FIXED Procedure Description Limitations/ Pre-Authorizations D C o - Resi ith o le etal NA D C o - Poelai Fused to High No le Metal NA D C o - Poelai Fused to Base Metal NA D C o - Poelai Fused to No le Metal NA D C o - / Cast High No le Metal NA D C o - / Cast P edo. Base Metal NA D C o - / Cast Fused to No le Metal NA D C o - / Poelai /Ce a i NA D C o - Full Cast High No le Metal NA D C o - Full Cast P edo i atel Base Metal NA D C o - Full Cast No le Metal NA D Coe to Ba NA D Re e e t B idge NA D St ess B eake NA D P e isio Atta h e t NA D Post a d Co e i Additio to Fi ed Pa tial De tu e Retai e, I di e tl Fai ated NA D P efai ated Post a d Co e i Additio to Fi ed Pa tial De tu e Retai e NA D Co e Build Up fo Retai e, Iludi g A Pi s NA D Copi g - Metal NA D Ea h Additio al I di e tl Fai ated Post - Sa e Tooth NA D Ea h Additio al P efai ated Post - Sa e Tooth NA ORAL SURGERY D E t a tio, Co o al Rea ts - De iduous Tooth NA D E t a tio - E upted Tooth o E posed Root E aluatio &/o Foeps Re o al * of D o D pe ea D Su gi al Re o al of E upted Teeth* *P e-autho izatio e ui ed fo No - E e ge ; suppo ti g do u e tatio e ui ed No -e e ge PA adiog aphi i age -E e ge PA adiog aphi D Re o al of I pa ted Tooth - Soft Tissue NA D Re o al of I pa ted Tooth - Pa tiall Bo NA D Re o al of I pa ted Tooth - Co pletel Bo NA D Re o al of I pa ted Tooth - Co pletel Bo, ith U usual Su gi al Co pli atio s NA D Su gi al Re o al of Residual Tooth Roots NA D O a t al fistula losu e NA Member Pays D Tooth Rei pla tatio a d/o Sta ilizatio of Aide tall E ulsed o Displa ed Tooth NA Tooth T a spla tatio iludes ei pla tatio f o o e site to a othe a d spli ti g a d/o D sta ilizatio NA D Su gi al E posu e of I pa ted U e upted Tooth fo O tho Reaso s NA D Biops of O al Tissue - Ha d NA D Biops of O al Tissue - Soft NA D Su gi al epositio i g of teeth NA D Al eoplast i Co jutio ith E t a tio s fou o o e teeth o tooth spa es pe uad NA D Al eoloplast i Co jutio ith E t a tio s- o e to th ee teeth o tooth spa es, pe uad NA D Al eoplast ot i Co jutio ith E t a tio s- fou o o e teeth o tooth spa es pe uad NA Al eoloplast ot i Co jutio ith E t a tio s- o e to th ee teeth o tooth spa es pe D uad NA D Vesti uloplast - idge e te sio se o da epithelial NA

13 Code ORAL SURGERY D Procedure Description Limitations/ Pre-Authorizations Member Pays Vesti uloplast - Ridge E te sio iludi g soft tissue g afts, us le eatta h e t, e isio of soft tissue atta h e t a d a age e t of h pe t ophied a d h pe plasti tissue NA D Eisio of e ig lesio up to. NA D Eisio of e ig lesio g eate tha. NA D Eisio of e ig lesio, o pli ated NA. D Eisio of Malig a t Tu o - Lesio dia ete up to. NA D Eisio of Malig a t Tu o - Lesio dia ete g eate tha. NA D Re o al of e ig odo toge i st o tu o -lesio dia ete up to. NA D Re o al of e ig odo toge i st o tu o -lesio dia ete g eate tha. NA D Re o al of e ig o odo toge i st o tu o -lesio dia ete up to. NA D Re o al of e ig o odo toge i st o tu o -lesio dia ete g eate tha. NA D Dest u tio of lesios ph si al o he i al ethod, epo t NA D Re o al of late al e ostosis a illa o a di le NA D Re o al of to us palati us NA D Re o al of to us a di ula is NA D Iisio a d d ai age of a s ess-i t ao al soft tissue NA Iisio a d d ai age of a s ess - i t ao al soft tissue - o pli ated iludes d ai age of D ultiple fas ial spa es NA D Iisio a d d ai age of a s ess-e t ao al soft tissue NA Iisio a d d ai age of a s ess-e t ao al soft tissue - o pli ated iludes d ai age of D ultiple fas ial spa es NA D Re o al of Fo eig Bod f o Mu osa, Ski, o Suuta eous Al eola Tissue NA D Re o al of ea tio -p odu i g fo eig odies, us uloskeletal s ste NA D Pa tial oste to/se uest e to of e o al of o - ital o e NA D Ma illa Si usoto fo Re o al of Tooth F ag e t o Fo eig Bod NA D Al eolus- losed edu tio, a ilude sta ilizatio of teeth NA D Olusal o thoti de i e, epo t NA D Osteoplast - fo o thog athi defoities NA Osseous, osteope iosteal, o a tilage g aft of the a di le o a illa - autoge ous o o autoge ous, D epo t NA D F e ule to NA D F e uloplast NA D Eisio of h pe plasti tissue pe ah NA D Eisio of Pe i o o al Gi gi a NA D Closu e of Sali a Fistula NA D Li ited O thodo ti T eat e t of the P i a De titio NA D Li ited O thodo ti T eat e t of the T a sitio al De titio NA D Li ited O thodo ti T eat e t of the Adoles e t De titio NA D Li ited O thodo ti T eat e t of the Adult De titio NA D Co p ehe si e O thodo ti T eat e t of the T a sitio al De titio NA D Co p ehe si e O thodo ti T eat e t of the Adoles e t De titio NA D Co p ehe si e O thodo ti T eat e t of the Adult De titio NA D P e-o thodo ti T eat e t Visit NA D Pe iodi O thodo ti T eat e t Visit as pa t of o t a t NA D O thodo ti Rete tio e o al of appliaes, o st u tio a d pla e e t of etai es NA

14 Code ADJUNCTIVE GENERAL SERVICES Procedure Description Limitations/ Pre-Authorizations D Palliati e E e ge T eat e t of De tal Pai Mi o P o edu e NA D Fi ed Pa tial De tu e Se tio i g NA D Lo al A esthesia Not i Co jutio ith Ope ati e o Su gi al P o edu es NA D Regio al Blo k A esthesia NA D T ige i al Di isio Blo k A esthesia NA D Lo al A esthesia NA D Deep sedatio /ge e al a esthesia ea h i ute i e e t NA D A algesia - aiol sis, i halatio of it ous o ide NA D I t a e ous ode ate o s ious sedatio /a algesia ea h i ute i e e t NA D No -i t a e ous Co s ious Sedatio NA Co sultatio - Diag osti Sei e P o ided De tist o Ph si ia othe tha Re- D uesti g De tist o Ph si ia NA D House/E te ded Ca e Fa ilit Call NA D Hospital all NA D Off e Visit fo O seatio Du i g Regula l S heduled Hou s NA D Off e Visit - Afte Regula l S heduled Hou s NA D Case P ese tatio, Detailed a d E te si e T eat e t Plai g NA D Off e Visit - Pe Visit Iludi g All Fees fo Ste ilizatio a d/o I fe tio Co t ol NA D The apeuti pa e te al d ug, si gle ad i ist atio NA D The apeuti pa e te al d ugs, t o o o e ad i ist atio s, diffe e t edi atio s NA D Medi i al Appli atio /iigatio Pe Visit NA D Appli atio of dese sitizi g edi a e ts NA D Fai atio of Athleti Mouthgua d NA D Olusio a al sis - ou ted ase NA D Olusio Adjust e t - Li ited NA D Olusio Adjust e t - Co plete NA D E a el Mio aasio NA D E teal lea hi g - pe ah NA D E teal Blea hi g - Pe Tooth NA D I teal lea hi g - pe ah NA B oke Appoi t e t Less tha Hou Noti e - pe i ute u it - a i u D $ NA Member Pays La fees a e ot iluded a d shall ot eeed $ 5 pe p o edu e, he e appli a le

15 Li itatio s & Elusio s Elusio s:. Sei es hi h, i the opi io of the Ge e al De tist o Spe ialist, a e ot e essa fo the patie t's de tal health.. Cos eti o e pe i e tal de tal sei es, a d/o p o edu es ot ge e all pe foed i a Ge e al De tist off e.. Cost of hospitalizatio a d/o phaa euti als.. Sei es that aot e pe foed e ause of the ge e al health of the patie t.. Sei es hi h a e ot o siste t ith the usual a d usto a sei es p o ided the Ge e al De tist o Spe ialists. A de tal t eat e t sta ted p io to the ee 's effe ti e date.. Sei es fo i ju ies a d/o o ditio s hi h a e paid o pa a le u de Wo ke 's Co pe satio o E plo e Lia ilit La s.. T eat e t fo sts, eoplas s a d alig aies.. Sei es p o ided ithout ost to the Su si e the go e e t o a age the eof, o a u i ipalit, ou t a d othe su di isio s.. The ost of p e ious etal used i a fo of de tal e efits.. A p o edu e ot spe ifi all listed as a o e ed e efit i the S hedule of Be efits.. Cost of de tal a e o e ed u de a auto o ile, edi al o o-fault o si ila t pe i su ae. Fi ed idge o k is ot o e ed.. Seala ts applied to a teeth a e ot o e ed. Li itatio s: Ge e al. All sei es ust e p eautho ized p io to t eat e t, eept diag osti, p e e ti e, filli gs a d e e ge e t a tio s OR lai s ill e de ied. Sei es ust e i di idualized, spe ifi, o siste t ith spto s o o fied diag osis of the ill ess o i ju u de t eat- e t, a d ot i eess of the e ipie t's eed.. Sei es ust efle t the le el of sei es that a e safel fuished, a d fo hi h o e uall effe ti e a d o e o seati e o less ostl t eat e t is a aila le state ide.. Sei es ust e fuished i a ae ot p i a il i te ded fo the oe iee of the ee, the ee 's a etake, o the p o ide.. U spe ified p o edu es a e ot o e ed ithout a epo t de o st ati g sei es p o ided a e o e ed u de the tes of the elusio s a d li itatio s.. I t a e ous o s ious sedatio is li ited to edi all e essa o e ed o al su ge.

16 Li itatio s & Elusio s Diag osti s. Diag osti sei es iluded the o al e a i atio, a d sele ted adiog aph eeded to assess the o al health, diag ose o al patholog, a d de elop a ade uate t eat e t pla fo the ee ' o al health. Reiu se e t fo so e adiog aphs of the sa e tooth o a ea a e de ied if A gus detei es that the ue to e edu da t, eessi e o ot i keepi g ith the fede al guideli es elati g to adiatio e posu e. The a i u a ou t paid fo i di idual adiog aphs take o the sa e da ill e li ited to the allo ae fo full outh se ies. Fo e a ple a Pa o a i - a a d Bite i gs take i a da ill e o side ed as a Full outh - a D.. Reiu se e t fo adiog aphs is li ited to those fil s e ui ed fo p ope t eat e t a d/o diag osis.. All adiog aphs ust e of good diag osti ualit, p ope l ou ted, dated a d ide tified ith the e ipie t's a e a d date of i th. Su sta da d adiog aphs ill ot e eiu sed fo, o if al ead paid fo, A gus ill e oup the fu ds p e iousl paid.. A gus utilizes the guideli es pu lished the Depa t e t of Health a d Hu a Sei es fo De i es a d Radiologi al Health. Ho e e, please o sult the follo i g e efit g id fo e efit li itatio s. Resto ati es. Reiu se e t iludes lo al A esthesia. Sei es a e li ited to esse tial sei es to esto e a d ai tai de tal health. Resto atio is ot o e ed o p i a teeth if loss is e pe ted ithi o ths.. Pae t is ade fo esto ati e sei es ased o the ue of su fa es esto ed, ot o the ue of esto ati e pe su fa e, o pe tooth pe da. A esto atio is o side ed a t o o o e su fa e esto atio o l he t o o o e a tual tooth su fa es a e iol ed, hethe the a e oe ted o ot.. Tooth p epa atio, all adhesi es iludi g a alga a d esi o di g age ts, a id et hi g, opalite, li e s, ases, di e t a d i di e t pulp aps, u i g, a d polishi g a e iluded as pa t of the fee fo esto atio. Billi g a d eiu se e t fo ast os a d post & o es o a othe fi ed p ostheti s shall e ased o e e tatio date.. Whe esto atio s iol i g ultiple su fa es a e e uested o pe foed, that a e outside the usual a ato i al e pe tatio, the allo ae is li ited to that of a o e-su fa e esto atio. A fee ha ged i eess of the allo ae fo the o esu fa e esto atio is disallo ed. E dodo ti s. Pae t fo oe tio al oot a al the ap is li ited to t eat e t of pea e t teeth o etai ed p i a teeth ith o sueda eous pea e t teeth. E dodo ti the ap fo p i a teeth ith sueda eous pea et teeth is li ited to pulpal the ap.. Root the ap is eiu sa le: a fo teeth that has esto ati e os, if the p og osis of the tooth is ot uestio a le fo pe iodo tal easo s, a d if e foliatio of a de iduous tooth is ot a ti ipated ithi eightee o ths.. The sta da d aepta ilit e plo ed fo e dodo ti p o edu es e ui es that the a al s e o pletel sealed api all a d late all. I ases he e the oot a al fili g does ot eet A gus's t eat e t sta da ds, A gus a e ui e the p o edu e to e edo e at o additio al ost. A eiu se e t al ead ade fo a i ade uate sei e a e e ouped afte a post pae t e ie. A pulpoto o palliati e t eat e t is ot to e illed i o ju tio ith a oot a al t eat e t.. Pulpoto ies ill e li ited to p i a teeth o pea e t teeth ith io plete oot de elop e t

17 Li itatio s & Elusio s E dodo ti s o t. The fee fo oot a al the ap iludes diag osis, e ti patio t eat e t, te po a filli gs, filli gs a d o tu atio of oot a als, a d p og ess adiog aphs. A o pleted fill adiog aph is also iluded.. Filli g ate ial ot aepted FDA e.g. Sa ge ti filli g ate ial is ot o e ed P osthodo ti s. P o isio fo e o a le p ostheses he asti ato futio is i pai ed, o he e isti g p ostheses is u sei ea le a d he e idee is suitted that i di ates that the asti ato i suff ie a e likel to i pai the ge e al health of the ee.. App o al fo pa tial de tu es to epla e poste io teeth ill ot e allo ed if the e a e i ea h uad a t at least th ee pe iodo tal sou d poste io teeth i fai l good positio a d olusio ith opposi g de titio. App o al fo ast pa tial de tu es fo a te io teeth ge e all ill ot e gi e u less o e o o e teeth i the sa e ah a e issi g. Pa tial de tu es a e ot a o e ed e efit he o o e poste io teeth a e i olusio.. De tu es ill ot e app o ed he : a de tal histo e eals that a o all de tu es ade i e e t ea s ha e ee u satisfa to fo easo s that a e ot e edia le e ause of ph siologi al o pshologi al easo s, o epai, eli i g o e asi g of the patie t's p ese t de tu es ill ake the sei ea le.. A p efoed de tu e ith teeth al ead ou ted foi g a de tu e odule is ot a o e ed sei e.. Billi g a d eiu se e t fo pa tials a d de tu e shall e ased o deli e date, a d ust ilude the sig ed a d dated "Patie t A k o ledge e t of T eat e t" fo..deli e of e o a le p ostheses iludes up to th ee adjust e ts ithi si o ths of the deli e fo a o plete o pa tial de tu e a d ithi th ee o ths of the deli e fo iediate de tu es.. No pa tial de tu es fo a si gle tooth ill e o e ed u less epla i g a a te io tooth. Reiu se e t fo a all-a li i te i pa tial Flippe is li ited to the epla e e t of a te io teeth i a i stae.. Reli es ilude all e essa adjust e ts fo a pe iod of si o ths f o the date of the eli e. A eli e usi g a light- u ed te h i ue is a hai side eli e. Reli es a e li ited to oe pe de tu e pe ea. I itial eli es a e li ited to o ea lie tha th ee o ths afte the date of i se tio fo iediate de tu es a d li ited to o ea lie tha si o ths afte seati g fo a o plete de tu e.. De tu e adjust e ts pe foed o the sa e date of sei e as eli es o epai s a e ot o e ed. O al Su ge. Reiu se e t iludes lo al a esthesia a d outi e post-ope ati e a e. P oph la ti e t a tio of aspto ati i pa ted o e upted teeth is ot a o e ed e efit. Spto ati o ditio s ould ilude pai a d/o i fe tio o de o st ated alolusio ausi g a shifti g of e isti g de titio.. Co e ed sei es fo o al su ge a e li ited to alle iatio of pai o i fe tio a d a e li ited to e t a tio s a d the iisio a d d ai age of a a s ess, u less esse tial to the p epa atio of the outh fo de tu es.. The iide tal e o al of a st o a lesio atta hed to the oot s of a e t a tio is o side ed pa t of th e t a tio o su gi al fee a d should ot e illed as a sepa ate p o edu e

18 Mee Rights & Respo si ilities POLICY: Flo ida la e ui es that ou health a e p o ide o health a e fa ilit e og ize ou ights hile ou a e e ei i g edi al a e a d that ou espe t the health a e p o ide s o health a e fa ilit s ight to e pe t e tai eha io o the pa t of patie ts. You a e uest a op of the full te t of this la f o ou health a e p o ide o health a e fa ilit. PROCEDURE: A patie t has the ight to:. e t eated ith ou tes a d espe t, ith app e iatio of his o he i di idual dig it, a d ith p ote tio of his o he eed fo p i a.. a p o pt a d easo a le espo se to uestio s a d e uests.. k o ho is p o idi g health a e sei es a d ho is espo si le fo his o he a e.. k o hat patie t suppo t sei es a e a aila le, iludi g hethe a i te p ete is a aila le if he o she does ot speak E glish.. k o hat ules a d egulatio s appl to his o he o du t.. e gi e the health a e p o ide i foatio oei g diag osis, plaed ou se of t eat e t, alteati es, isks, a d p og osis.. efuse a t eat e t, eept as otheise p o ided la.. e gi e, upo e uest, full i foatio a d e essa ou seli g o the a aila ilit of k o fi aial esoues fo his o he a e.. k o, upo e uest a d i ad ae of t eat e t, hethe the health a e p o ide o fa ilit aepts the patie t s pla e efit o e age.. e ei e, upo e uest, p io to t eat e t, a easo a le esti ate of ha ges fo health a e sei es.. e ei e a op of a easo a l lea a d u de sta da le, ite ized ill a d, upo e uest, to ha e the ha ges e plai ed.. i pa tial aess to t eat e t o aoodatio s, ega dless of a e, atio al o igi, eligio, ha di ap, o soue of pae t.. t eat e t fo a e e ge o ditio that ill dete io ate f o failu e to p o ide t eat e t.. k o if t eat e t is fo pu poses of e pe i e tal eseah a d to gi e his o he o se t o efusal to pa ti ipate i su h e pe i e tal eseah.. e p ess g ie aes ega di g a iolatio of his o he ights, as stated i Flo ida la, th ough the g ie ae p o edu e of the p o ide o fa ilit that seed hi o he a d to the app op iate state li e si g age.. to pa ti ipate ith the p o ide i aki g de isio s a out the health a e he o she e ei es a d p o ide i put i to plaed t eat e t.. e ei e i foatio a out A gus, its sei es, p o ide s a d ee /patie ts' ights a d espo si ilities.. pa ti ipate ith the p o ide i aki g de isio s a out his o he health a e.. ha e a a did dis ussio a out app op iate o edi all e essa t eat e t optio s fo ou health o ditio s, ega dless of ost o e efits.. oi e o plai ts o appeals a out A gus o the a e it p o ides.. ake e oe datio s a out A gus' ee ights a d espo si ilities poli ies.. e ei e i foatio a out ad ae di e ti es, p o ide s ede tials a d a see of alp a ti e o e age.. ha ge p o ide s if othe p o ide s a e a aila le.

19 Mee Rights & Respo si ilities A patie t has the espo si ilit :. to p o ide to A gus a d its p o ide s, to the est of his o he k o ledge, au ate a d o plete i foatio a out p ese t o plai ts, past ill esses, hospitalizatio s, edi atio s, a d othe atte s elati g to his o he health.. to epo t u e pe ted ha ges i his o he o ditio to the p o ide.. to epo t to the p o ide hethe he o she o p ehe ds a o te plated ou se of a tio a d hat is e pe ted of hi o he.. to u de sta d his o he health p o le s a d pa ti ipate i de elopi g utuall ag eed-upo t eat e t goals to the deg ee possi le.. to follo the t eat e t pla e oe ded the p o ide.. to keep appoi t e ts a d, he he o she is u a le to do so fo a easo, ill otif the p o ide o fa ilit.. fo his o he a tio s if he o she efuses t eat e t o does ot follo the p o ide 's i st u tio s.. to assu e the fi aial o ligatio s of his o he a e a e fulfilled as p o ptl as possi le.. to follo fa ilit ules a d egulatio s affe ti g patie t a e a d o du t.. to i fo his o he p o ide a out a li i g ill, edi al po e of attoe, o othe di e ti e that ould affe t his o he a e.. to p o ide a espo si le adult fo t a spo tatio f o the fa ilit if e ui ed the p o ide i situatio s he e sedatio is ad i iste ed. P o ide s a e e ui ed to p o ide sei es that a e:. Not disi i ati g agai st a patie t i a ae iludi g ut ot li ited to: a Soue of pae t Ra e Eth i it d Natio al o igi e Se f Se ual o ie tatio g Age h Religio i Pla e of esidee j Health status k Me tal o ph si al disa ilit l Clai s e pe iee Medi al histo E idee of i su a ilit o Ge eti i foatio. P esei g patie t dig it a d o sei g the ights of patie ts.. A idi g all ad i ist ati e a d edi al poli ies a d p o edu es esta lished A gus.. P o idi g all sei es i a ultu all o pete t ae a d aoodati g patie ts ith disa ilities.. P o idi g patie ts ith o plete i foatio oei g thei diag osis, t eat e t, a d p og osis a d gi i g the the oppo tu it to pa ti ipate i de isio s iol i g thei health a e.

20 Co plai ts a d G ie aes I foal G ie aes: A Mee ho has a g ie ae agai st A gus De tal & Visio, I. ADVI fo a atte a isi g f o a Su si e Ce tifi ate o fo o e ed sei es e de ed he eu de a suit a i foal o al g ie ae to ADVI. Assistae ith ADVI s g ie ae p o edu es, iludi g assistae ith i foal o al g ie aes, a e o tai ed alli g ADVI s Mee Sei es Depa t e t at -. O al g ie aes shall e suitted to ADVI s G ie ae & Appeals Depa t e t. I foal o al g ie aes shall e espo ded to as soo as possi le the G ie ae Coo di ato. If the i fo - al o al g ie ae iol es a edi al- elated atte o lai, a de tist shall e iol ed i esol i g said g ie ae. The Mee has the ight to file a foal itte g ie ae ith ADVI a d to appeal to the Flo ida Depa t e t of Fi aial Sei es. Suissio of Foal G ie aes: A Mee ho has a g ie ae agai st ADVI fo a atte a isi g out of the Ce tifi ate o o e ed sei es e de ed he eu de a suit a foal itte state e t of the g ie ae to ADVI. Su h itte state e t shall e spe ifi all ide tified as a g ie ae a d shall e suitted to ADVI ithi si t da s f o the date of the ouee. The itte g ie ae shall o tai a state e t of a tio e uested the Mee ; the Mee s a e, add ess, telepho e ue, ee ue ; the a e of the Su si e s Pa ti ipati g Ge e al De tist o Pa ti ipati g Spe ialist; a d the Su si e s sig atu e a d the date. The state e t should e se t to ADVI s G ie ae Coo di ato at ADVI s add ess as set fo th he ei. Mo e i foatio o ADVI s g ie ae p o edu es a e o tai ed alli g ADVI s Me - e Sei es Depa t e t at ADVI s telepho e ue set fo th a o e. E pedited G ie aes: ADVI ill o fi e eipt of the Mee s e pedited g ie ae, o all, ithi t e t -fou hou s. ADVI ill esol e the e pedited g ie ae ithi se e t -t o hou s a d ill ou i ate the esolutio o all a d i iti g to the Mee. Respo se to Foal G ie aes: ADVI ill o fi e eipt of the Mee s g ie ae, i iti g, ithi fi e usi ess da s. ADVI ill esol e the g ie ae a d ou i ate the esolutio, i iti g, ithi thi t da s. The ti ef a e a e e te ded up to thi t da s if the Mee asks fo a e te sio o the Pla do u e ts that additio al i foatio is eeded a d the dela is i the Mee s i te est. A g ie ae is ot o side ed foal u til the Pla e ei es a itte sua f o the Mee. Appeal of De isio : If the a tio take the Pla is ot satisfa to to the Mee, the Mee a appeal the atte to the Pla ithi thi t da s afte e ei i g oti e of the esolutio. The Mee s e uest fo a appeal ust e suitted to the pla i iti g, a d should e di e ted to: A gus De tal & Visio, I., G ie ae Depa t e t, W. State St., Ta pa, FL. The Pla ill esol e all appeals a d ou i ate the esolutio, i iti g, ithi thi t da s. If the Mee is dissatisfied ith the appeal de isio, the Mee has the ight to appeal to the State of Flo ida Depa t e t of Fi aial Sei es a d/o the Off e of I su ae Regulatio of the Fi aial Sei es Coissio.

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