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CALIFORNIA DENTAL SERVICE <br /> <br /> A Nonprofit Corporation <br /> CDSGROUP # 210S <br /> <br />APPLICATION FOR DENTAL CARE SERVICE AGREEMENT <br /> <br /> CITY OF REDWOOD CITY <br /> <br />herein called "EMPLOYER", hereby applies for a DENTAL CARE SERVICE AGREEMENT with CALIFORNIA <br />DENTAL SERVICE, herein called "CDS", on the following terms: <br /> <br /> I. Definitions: <br /> <br /> A. Monthly Payment: <br /> The sum of $14~.40 £o~ each eligible employee. <br /> <br /> B. Applicable Percentages: <br /> [] Basic Benefits (as defined in Appendix "C") 80 % <br /> [~ Prosthodontics (as defined in Appendix "C'°) 80 % <br /> <br /> II. Benefits provided and limitations: <br /> <br /> A. Subject to the terms and conditions herein specified, CDS shall pa'/ or otherwise discharge the applicable <br />percentage of the lesser of the usual, customary and reasonable fees or the fees actually charged for services rendered to <br />an eligible patient during the term hereof and covered by this Agreement set forth in Appendix "C" attached hereto. <br /> <br /> B. The amounts payable by CDS for covered Basic and Prosthodontic services rendered by a participating dentist in <br />California who is not a member of CDS shall not exceed the applicable percentage of the amounts shown for correspon- <br />ding services in the Table of Allowances, attached hereto as Appendix "B"; and the amounts payable by CDS for covered <br />services rendered by a participating dentist outside of California shall not exceed the applicable percentage of the <br />customary fees in California. <br /> <br /> C. The amounts payable to a dentist who is not a participating dentist shall not exceed the amount which CDS <br />would pay to such a dentist on account of such services [f he were a participating dentist, but not a member of CDS. <br />Such payment shall be made only upon receipt by CDS of evidence which it deems satisfactory showing the rendition of <br />covered services during a period in which the patient was eligible for care under the provisions of this Agreement and the <br />amount which the patient has paid or become obligated to pay therefor. Such payment may, in the discretion of CDS, be <br />made to the eligible patient, to the dentist, or jointly to both of them. <br /> <br /> [~]D1. The maximum amount payable by CDS for Basic and Prosthodontic Services rendered to an eligible <br />patient in any calendar year or portion thereof shall be $1 · 000. 00 <br /> <br /> [-~D2, The maximum amount payable by CDS for Orthodontic Benefits (as defined in Appendix "C") rendered <br />to an eligible patient shall be $ <br /> <br /> <br />