SmileSavers Contract
Review the plan details, select your coverage, enter member information (if applicable), then complete and sign the agreement.
Plan details
Synergy Dental Solutions · Dr. Angie Tenholder, DMD, FAACP, DABCDSM, FAGD · 1000 Eleven South, Suite 3F, Columbia, IL 62236 · Phone (618) 281-9729 · Fax (618) 281-9734 · WeCare@WeAreSynergy.com
The SmileSavers Dental Discount Plan is offered exclusively by Synergy Dental Solutions and available only at 1000 Eleven South, Suite 3F, Columbia, Illinois. Dr. Angela Tenholder is a licensed dentist through the State of Illinois, has Fellowship Status in the Academy of Craniofacial Pain and is a Diplomate of the American Board of Craniofacial Dental Sleep Medicine. If there is a change in Dr. Tenholder's licensure and certification status, you will be notified immediately.
No deductibles
No claim forms
No pre-authorization requirements
No pre-existing condition limitations
No waiting periods for eligibility
No yearly maximum
No benefits given for procedures that are provided by dental specialists outside of our office. (In the event Dr. Tenholder feels that it is in your best interest to receive care from another provider.)
No benefits are available if used in conjunction with a workers' compensation, automobile insurance claim or hospitalization.
YEARLY FEES
Individual Coverage $350
Dual Coverage* $550
Family Coverage (3 members)** $730
Family Coverage (4 members)** $950
If you have more than 4 members in your family, there will be an additional $180 to the cost of the coverage. Example, if you have 5 members in your family, the cost of your coverage will be $950 + $180 = $1,130.
* The dual plan is for legally married couples or parent/child
** The family plan includes dependent children up to age 26
COVERAGE TABLE
$5 copay: Two cleanings and check-ups a year
Covered at 100%: Comprehensive exam for new patients · Periodic exams (two a year) · One limited emergency exam a year · Complete x-ray series (every three years) · Bitewing x-rays (once a year) · All intraoral x-rays
50% off: Sealants · Space maintainers · Periodontal maintenance
35% off: Periodontal services (full-mouth debridement, scaling and root planing)
25% off: Fillings · Crowns · Bridges · Implants and implant abutments · Dentures and partials (including relines and repairs) · Oral surgery · Root canals · Additional emergency exams · After-hours fees · Night guards not related to sleep apnea, snoring or headaches
Orthodontics: $500 off orthodontic treatment (does not apply to NeuralFORM Dental Device Therapies)
RENEWAL OF THIS AGREEMENT
You will be contacted within 30 days of the renewal/expiration date on this contract. If you agree to continue coverage, your yearly premium will be due prior to the renewal date. There will be a $50 penalty for late payment of the renewal premium. Fees aren't refundable once any service has been provided. After the agreement has been executed and yearly deductible paid, this agreement will continue to be in effect.
TERMINATION OF THIS AGREEMENT
Termination of this contract will have no less than 30 days prior written notice by either party who wishes to terminate the contract without cause. The rights and responsibilities under the contract cannot be sold, leased, assigned, assumed or otherwise delegated by either party without the prior written consent of the other party. Since Dr. Tenholder is the only health care provider, there will be no transfer of plan administration. The assignee must comply with all the terms and conditions of the contract being assigned, including all appendices, policies and fee schedules.
Dr. Tenholder will maintain adequate professional liability and malpractice coverage, through insurance, self-funding, or other means satisfactory to the administrator. Synergy Dental Solutions must be notified within no less than ten days after Dr. Tenholder's receipt of notice of any reduction or cancellation of such coverage.
Dr. Tenholder will provide health care services without discrimination against any beneficiary on the basis of participation in the preferred provider program, source of payment, age, sex, ethnicity, religion, sexual preference, health status or disability.
Plan and members
Plan selected
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Individual
Dual
Family (3)
Family (4)
Family (5 or more)
Number of members
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Members covered (name and date of birth for each)
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Effective date
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Renewal/expiration date
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signatures
By signing, I agree to the SmileSavers Contract above.
Patient name
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First Name
Last Name
Is the patient a minor?
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Yes
No
Patient signature
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If a minor, signature of parent or guardian
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Date
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
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