miragefamilydentistry.com - Dental Savings Plan Agreement

Mirage Family Dentistry Dental Savings Plan Agreement
Administrative Guidelines
1. The Dental Savings Plan is NOT dental insurance. It is a discount savings program. This plan intends to benefit patients without dental insurance and cannot be combined with any other dental insurance.
2. This plan is only eligible to be used at Mirage Family Dentistry. Therefore, if you are referred to the specialist, they will NOT offer any discounts included in the plan.
3. This plan is that non-transferrable family members cannot be substituted for another family member. Benefits such as exams and X-rays are not rolled over if unused within a year.
4. This enrollment form and Agreement and Acknowledgment, signed by the Dental Savings Plan member or Guarantor (herein referred to as "patient" or "member"), and accepted by Mirage Family Dentistry, shall be considered to be the contract, membership materials and all disclosure information relating to the Dental Savings Plan.
5. This plan is non-refundable- No Refunds will be given if a patient chooses not to use their dental plan.
6. Rates are subject to change annually.
7. Membership premium is due at the time of the first exam. No discount will be given until the membership premium is paid in full.
8. Dependents are children or legal dependents who are unmarried, 18 years of age, and younger.
9. The patient is responsible for the entire dental bill payment after the discount is applied when services are rendered.
10. Canceling/rescheduling needs to be done within 48 hours before the appointment. There is a $100 fee for the first time; the second time occurrence is $100 and losing membership privileges.
11. Mirage Family Dentistry reserves the right to change discounted fees once a year. Usually, such changes are made during the first quarter of each calendar year. Yearly membership premium fees may be changed at the beginning of a new contract term, with notice given to the member at the time of renewal.
12. The plan is valid for one year from the date this is signed, and the premium is paid.
13. This eligibility for the plan is completely at the Doctor's discretion, and any patient considered to be a non-fit in the relationship will lose benefits immediately.
Membership Type
Basic Membership $200 (each adult member)For all dependents $150 (age 18 or under)
Additional Dependent Member(s)
Total
$200 each x number of dependents
Members
Primary Subscriber Name
Date of Birth

MonthDayYear
Address
City, State, Zip
Social Security Number
Cell Phone Number*
Please enter a valid phone number.
Home Phone Number
Please enter a valid phone number.
Email Address*
example@example.com
Spouse / Partner Name
Date of Birth

MonthDayYear
Agreement and Acknowledgement
I acknowledge receiving, reading, and understanding the terms of the Mirage Family Dentistry Dental Savings Plan. I agree to abide by all terms outlined above. I understand that all discounted fees are due at the time of service for the treatment rendered. I understand that this is NOT dental insurance but a dental discount savings Plan.
Guarantor Signature

Clear
Name

First NameLast Name
Date

MonthDayYear
Should be Empty:

Mirage Family Dentistry Dental Savings Plan Agreement

Administrative Guidelines

Membership Type

Members

Agreement and Acknowledgement