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DR. GREEN DENTAL CARE PLAN SIGN UP

 

 

 

 

Name______________________________________ Date_______________

  

Name______________________________________________

  

Child_______________________________________________

  

Child_______________________________________________

 

 

 

PAYMENT OPTIONS

 

 

Individual

One annual payment $339.00

Each Child

One annual payment $249.00

 

 

SERVICES PROVIDED AT NO CHARGE

 

Dental Cleaning

2 per year

Cavity detecting x-rays once per year

X-rays in conjunction with emergency services

Doctor

exam 1-2 per year

Fluoride treatments (under age 17)-2 per year

 

 

 

ADDITIONAL PROCESSING FEE FOR THIS ONE PROCEDURE:

  

Complete x-rays (or panoramic radiographs)once every 5 years= $15.00 Processing fee additional to plan

  

 

TERMS AND CONDITIONS

 

  1. For dental treatment, all fees are due on the date of service.

  2. Plan members receive a 15% discount on all Dr. Green Dental Care Services. This includes emergency exams.

  3. Anything not listed above is extra but is subject to the discount.

  4. Panoramic radiographs are subject to a $15.00 Processing fee.

  5. Annual fee may be made by cash or check.

  6. All plan commitments are for one year. Pro-rated discounts do not apply for early withdrawal.

  7. Cannot be combined with another insurance plan (i.e. Delta etc.)

  8. May be used with company sponsored pre-tax and flex spending accounts.

  9. May be used after insurance maximum has been reached.

  10. Plan fees cannot be financed by dental third party financing plans (i.e. Care Credit).

  11. It is the patient’s responsibility to keep up with their preventative maintenance schedule and x-rays. Our usual reminders are done as a courtesy only. Unused preventative maintenance visits cannot be carried over to a subsequent year.

  12. The plan does not cover out of office general or specialty care.

  13. The plan does not cover outstanding balances incurred prior to enrollment.

  14. This is not an insurance product.

     

     

    I understand all terms and conditions and agree to abide by them. All questions have been answered to my satisfaction.

     

     

     

     

     

     

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