Dela Rama Dental In House Membership Program

Adult Membership Plan

Includes:

2 cleanings, 2 periodic exams, 2 sets of routine x-rays/year, ($600 value)

1 emergency exam with set of emergency x-rays/year, ($300 additional value)

• Palliative treatment (the treatment necessary to take the patient out of pain) is a separate fee. (Can range from $150-300 depending on treatment)
  
• Can be used for an In Person/Virtual Doctor Consult

2 fluoride treatments per year ($120 additional value)

$250 off all orthodontic treatments (metal braces or Invisalign treatment)

10% discount off all restorative treatments (non orthodontic)

**Valid only at South San Francisco office**

Payment Options

Annual Plan Adults (age 18+)	Annual Plan Children (17 & under)
$575/year	$500/year

 Periodontal Patients:

Adult plan plus 2 extra cleanings (total of 4 cleanings/year)

$1100/year

Please read the following:

• This is NOT dental insurance.
• This an in-house dental membership plan that is ONLY good at Dela Rama Dental Care (South San Francisco Location). It is meant to be an alternative to purchasing traditional dental insurance.
• The ADULT PLAN can be a standalone plan, or can be used as a supplement for additional cleanings if that patient's insurance plan only allows for 2 cleanings per year.
• Valid with health savings accounts, flex spending accounts, and health reimbursement accounts.
• Payment options: Recurring Annual Charge
• Automatic credit card payment required on file for payment plans.
• Annual membership fee is due immediately, and recurring fees are automatically billed every year on the same date to a credit card on file.
• Please note a 3.5% surcharge applies to all credit card payments.
• Plans may be purchased with a financing programs such as Cherry or CareCredit with a 10% surcharge.
  
• In the event of a price increase, membership fees may be "grandfathered" for one additional year as long as the membership remains continuous and in good standing.
  
• Annual membership fee is nonrefundable after the first cleaning has been performed.
• If a membership plan's annual credit card charge is rejected, benefits will be cancelled IMMEDIATELY. Unused portions of an enrollment cycle month will not be refunded.
• Once a membership cycle is cancelled, patients must re-enroll as new members at the current price.
• Plans may be upgraded at any time without incurring any setup fees.
• Plan downgrades must wait until the next enrollment cycle to take effect.
• All benefits (exams, x-rays, cleanings, fluoride) must occur within a year of enrollment and cannot be carried over to the next year.
• Additional treatments (restorative work, extractions, root canals, etc) must be PAID IN FULL the day of treatment to qualify for the discount and keep the plan active.
  
• All fees will be based on the treating doctor's fee schedule and not any dental plan's fees.
• Program is not transferrable or sharable to another party or uncovered family member.
• Does not cover any portion of a specialist referral fee.
• Not applicable to hospitalization or hospital charges of any kind.
• Will not apply to dental care for injuries covered under worker's compensation.
• Will not apply to dental care for which, in the sole opinion of the treating dentist, lies outside the realm of their capability.
• If member uses their membership for a discount on braces or Invisalign, but cancels their plan before their balance is paid in full, that discount will be voided, and the remaining balance will due immediately.
• Benefit 10% discount applies to General Dentistry, Hygiene & Speciality Services performed in our office only.
• All orthodontics, including appliances, retainers & partial ortho treatments not eligible for the 10% discount.
• We reserve the right to change program terms at any time. We will notify you if your specific plan is modified.