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Guam Dental Insurance Alternative

We make caring for your families smiles affordable.

Online Enrollment Form

  1. Below, List yourself first and spouse (if any) second, and then all eligible children to be covered by this plan. Supporting documents will be required to enroll dependents with a different last name, common-law/domestic partner, step-children, legal guardians, foster children, and children over the age limit (11 years of age).

  2. The DSI Dental Discount Plan Enrollment Period is 12 months from the Month of Initial Enrollment. This Dental Discount Plan requires the member to stay enrolled for 12 consecutive months. Failure to maintain DSI Plan membership during the total enrollment period will result in the direct billing of all dental treatments rendered by the contracted dental center to the member at the “Fee for Service” schedule of payments, less the total amount of funds contributed to the plan that was allocated to the contracted dental center. Copies of the dental fees associated with your treatment plan utilization during the time you are enrolled with DSI can be requested from your dental provider at no charge. Should your account default in payment due to insufficient funds, you will be faced with a fee of $45.00 in addition to your monthly contribution. Failure to make your monthly contribution by the 1st week of every month, you will accrue a $10.00 late fee.

    I/We have read the terms of the DSI dental program enclosed in this packet. We do hereby apply for membership to the plan. We understand the rules and regulations of the plan as defined on this application and agree to be bound by the terms and conditions of the plan as herein defined. We agree to pay DSI the monthly contribution fee, upon acceptance into the plan, and to pay any and all additional fees directly to the providing dentists of the plan. We understand that services under this plan can only be received at participating DSI dental offices.

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278 S. Marine Drive Suite 203, Tamuning Guam 96913
Phone: (671) 646 - 3741 / Fax: (671) 646 - 3740