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PPO Versatile Plan 1 with Benefits-at-a-Glance WmHIP In-Network Out-of-Network Deductible, Copays/Coinsurance and Dollar Maximums Deductible - per calendar year Copays/Coinsurance Note : Services without a network are covered at the in-network level. Out-of-Pocket Maximum – per calendar year Lifetime Maximum Preventive Services – limited to $500 per
DENTAL AND MEDICAL INFORMATION Date_______________ Patient’s Name __________________________________________ DENTAL INFORMATION Have you ever had any serious trouble associated with previous dental treatment? If so, please describe _____________________________________________________________________ Does dental treatment make you nervous? ___ No ___ Slightly ___Moderately ___Ex