PLEASE INCLUDE A VOIDED CHECK OR DEPOSIT SLIP

Subsidiaries – SAFEGUARD - St. Louis Dental Service - Corporate Dental

Dental Source Dental Health Care Plans Membership Change Request Form

IMPORTANT - PLEASE READ Please complete the member information portion of this form regardless of your type of change. If you are changing checking accounts, or are converting from your employer’s plan to an Individual plan and wish to have your membership fees paid through monthly bank draft, please complete the authorization for electronic monthly installments on the back of this form. All changes must be received by Dental Source no later than the 25^th of the month to be effective by the 5^th of the following month.

MEMBER INFORMATION:

TYPE OF CHANGE:

q DENTIST q OTHER (Explain)

q CONVERTING TO AN INDIVIDUAL PLAN

q ADDRESS

q DEPENDENT

q CHANGING CHECKING ACCOUNTS

q TERMINATION

REASON FOR CHANGE: - (Attach additional page if needed.)

DEPENDENT INFORMATION: (Dependents are defined as a spouse, legally dependent children to age 19 and full time college students to age 23.

Part 2	_NAME _{LAST FIRST MI}	^{DATE OF BIRTH}	^SEX	_{RELATION TO APPLICANT}
q Add q Delete
q Add q Delete
q Add q Delete
q Add q Delete

DENTIST INFORMATION:

Part 3

If changing dentists, please select a participating general dentist from the Dental Source network. Be sure that the dentist you select accepts the plan you select and is accepting new patients. If you have questions regarding dentist in your area, please contact Dental Source at (816) 523-8900.

^{Selected Dental Location Name}

^{Office

Location Number}

Part 4

I HEREBY REQUEST THE ABOVE CHANGES BE MADE TO MY ACCOUNT WITH DENTAL SOURCE OF MISSOURI & KANSAS, INC.

^SIGNATURE

^DATE

BANK ACCOUNT INFORMATION

Authorization For Electronic Monthly Installments:

Complete this portion of the change form ONLY if you wish to pay for membership through automatic monthly bank draft. The Automatic Bank drafts are processed on the 15^th of every month. However, if the 15^th falls on a Saturday, Sunday or bank holiday, the draft will be processed on the following business day.

Part 1

^{1.
EMPLOYER NAME (if with a group plan)}

^{GROUP NUMBER}

^{MEMBER NUMBER}

^{2.
SOCIAL SECURITY NUMBER}

^{3.
NAME
(LAST)
(FIRST)
(MI)}

^{4.
ADDRESS}

^{(CITY)

(STATE)
(ZIP CODE)}

^{5.
WORK PHONE}

^{6
HOME PHONE}

^{7. DATE OF
BIRTH

(month/day/year)}

^SEX

^{q

Female

q

Male}

I hereby request and authorize Dental Source of Missouri & Kansas, Inc. to deduct a monthly membership fee from my account with the financial institution named below. This authority is to remain in effect until revoked by me in writing and until said written notice is actually received by Dental Source of Missouri & Kansas, Inc. I agree that Dental Source of Missouri & Kansas, Inc. shall be under no liability whatsoever upon processing these payments in accordance with said terms.

Bank Name Address City/State/Zip

________________________________________________ _________ _________

Routing Code Account Number Checking Savings

X_______________________________________________________________________________________________

MEMBER’S SIGNATURE DATE

ACH Electronic Draft Indemnification Agreement for your Financial Institution:

In consideration for your honoring pre-authorized payments drawn against depositors of your financial institution for the payment of membership fees to Dental Source of Missouri & Kansas, Inc. we agree that no liability or responsibility lapses shall be attached to your financial institution as a result of honoring such payments. We further agree to hold you harmless from and reimburse you for any loss resulting as a consequence to your agreement to honor such payments, and we shall defend any such action brought against you as a result of your agreement to honor such payments. This agreement was authorized in a resolution adopted by the Board of Directors of Dental Source of Missouri & Kansas, Inc.

CREDIT CARD INFORMATION

Authorization for Annual Credit Card Payment:

Complete this portion of the change form ONLY if you wish your membership fees to be charged to you and your VISA or MASTERCARD.

___VISA ___MASTERCARD Card Number:_________________________Expiration Date:__________

I hereby request and authorize Dental Source of Missouri & Kansas, Inc. to charge the credit card account listed above the annual membership fee to activate my membership with Dental Source of Missouri & Kansas, Inc. I understand that if, for whatever reason, the charge to the account listed above cannot be processed, benefits under the Dental Source program will not be activated and that I will be contacted by Dental Source for alternative payment options.

X ____________________________________________________________________________________

MEMBER’S SIGNATURE DATE