Application for Individual Dental Coverage Section 1 | Policyholder ...
Dental avings Plan Coverage Affordable Dental Coverage For ... · Family** (3) Family** (4) Each...
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Plan: Single Dual* Family** (3) Family** (4) Each additional Patients agree that the Center for Advanced Dentistry’s fees stated must be paid at the time services are rendered. Any service not paid for at the time of service will be billed at usual and customary fees. Plan fees are valid only when paid at the time of enrollment. All family members must reside in the same household. This is not an insurance product. Save over $1,400 compared to Average Dental Insurance in the first year! Dental $avings Plan BENEFIT PREMIUMS Total Annual Cost: $399 (savings of $200 off our normal fees) $675 (savings of $475 off our normal fees) $852 (savings of $720 off our normal fees) $985 (savings of $1,295 off our normal fees) $125 Coverage Compare Out-of-Pocket Fees Affordable Dental Coverage For Your Entire Family! Please ask one of our friendly front desk team members for an application or visit our website: HiTechSmiles.com Plan Premium, Product or Service Annual Premium (single) Annual Premium (family of 4) Deductible Cleaning & Exam (twice per year) Veneers Dental Implants Dental $avings Plan Membership $399 $985 $0 $0 $1,350 (That’s 10% OFF!) $2,335 (You’re saving $259!) Average Dental Insurance Costs $780 $1,592 $50 $0 $1,600 (not covered by most plans) $2,500 (not covered by most plans) Center for Advanced Dentistry’s Regular Prices $580 $2,320 $0 $310 $1,500 $2,594 Our basic plan for $399 will include: ✓ 1 Comprehensive Exam ✓ 1 Annual Exam ✓ 1 Emergency Exam (used any time during the year) ✓ 2 Cleanings (non-periodontal based) ✓ 2 Oral Cancer Screenings ✓ 2 Fluoride Tooth Desensitizing Treatments ✓ 4 Bitewing X-rays ✓ Any Individual X-rays needed throughout the year ✓ Full Mouth Series of X-rays or Panorex ✓ 15% OFF Additional Cleanings, Dental Sealants, Fillings, Core Buildups, Oral Surgery, Root Canals ✓ 10% OFF Crowns, Veneers, Periodontics, Dentures, Partials, Implants ✓ $500 OFF Invisalign ® , ClearCorrect™, Six Months Smiles™, and Inman Aligner™ ✓ $100 OFF ZOOM!™ Whitening Treatment: Member Discount: Diagnostic and X-rays Comprehensive Exam .............................................. 100% (new patient / initial visit) 1 Annual Exam ............................................................ 100% (children under 18 = 2 per year) 1 Emergency Exam .................................................... 100% (problem focused, 1 per year) 4 Bitewing X-rays (1 time per year) ............................. 100% Periapical, First Film ................................................... 100% Periapical, Each Additional Film ............................ 100% Complete Series X-rays or Panorex ...................... 100% (1 every 5 years) Preventative Child Prophylaxis (2 cleanings per year) ..................... 100% Adult Prophylaxis (2 cleanings per year) .................... 100% Fluoride (2 per year, no age limit) .................................. 100% Oral Cancer Screenings (2 per year) ......................... 100% Additional Cleanings per year .................................. 15% Dental Sealants ............................................................. 15% All Other Procedures Fillings and core buildups ......................................... 15% Oral Surgery ....................................................................15% Root Canals ..................................................................... 15% Crowns ............................................................................. 10% Veneers ............................................................................ 10% Periodontics ................................................................... 10% Dentures and Partials .................................................. 10% Implants ........................................................................... 10% ZOOM!™ Whitening ............................................ $100 OFF Invisalign ® , ClearCorrect™, Six Months Smiles™, and Inman Aligner™ *** ............................................. $500 OFF *The dual plan is for parent/child or husband/wife only. **The family plan includes family members and children under 18 or children who are enrolled in college full-time until the age of 23. ***An Invisalign, ClearCorrect, Six Month Smiles or Inman Aligner member must remain a plan member for the duration of treatment to retain discount plan benefits. Plus one-time $99 enrollment fee.
Transcript of Dental avings Plan Coverage Affordable Dental Coverage For ... · Family** (3) Family** (4) Each...
Plan:
Single
Dual*
Family** (3)
Family** (4)
Each additional
Patients agree that the Center for Advanced Dentistry’s fees stated must be paid at the time services are rendered. Any service not paid for at the time of service will be billed at usual and customary fees. Plan fees are
valid only when paid at the time of enrollment. All family members must reside in the same household. This is not an insurance product.
Save over $1,400 compared to Average Dental Insurance in the �rst year!
Dental $avings PlanBENEFIT PREMIUMS
Total Annual Cost:
$399 (savings of $200 o� our normal fees)
$675 (savings of $475 o� our normal fees)
$852 (savings of $720 o� our normal fees)
$985 (savings of $1,295 o� our normal fees)
$125
Coverage
Compare Out-of-Pocket Fees
Affordable Dental CoverageFor Your Entire Family!
Please ask one of our friendly front desk team
members for an application or visit our website:
HiTechSmiles.com
Plan Premium, Product or
Service
Annual Premium(single)
Annual Premium(family of 4)
Deductible
Cleaning & Exam(twice per year)
Veneers
Dental Implants
Dental$avings PlanMembership
$399
$985
$0
$0
$1,350(That’s 10% OFF!)
$2,335(You’re saving $259!)
Average Dental Insurance Costs
$780
$1,592
$50
$0
$1,600(not covered by
most plans)
$2,500(not covered by
most plans)
Center for Advanced Dentistry’s
Regular Prices
$580
$2,320
$0
$310
$1,500
$2,594
Our basic plan for $399 will include:
✓ 1 Comprehensive Exam
✓ 1 Annual Exam
✓ 1 Emergency Exam (used any time during the year)
✓ 2 Cleanings (non-periodontal based)
✓ 2 Oral Cancer Screenings
✓ 2 Fluoride Tooth Desensitizing Treatments
✓ 4 Bitewing X-rays
✓ Any Individual X-rays needed throughout the year
✓ Full Mouth Series of X-rays or Panorex
✓ 15% OFF Additional Cleanings, Dental Sealants, Fillings, Core Buildups, Oral Surgery, Root Canals
✓ 10% OFF Crowns, Veneers, Periodontics, Dentures, Partials, Implants
✓ $500 OFF Invisalign®, ClearCorrect™, Six Months Smiles™, and Inman Aligner™
✓ $100 OFF ZOOM!™ Whitening
Treatment: Member Discount:
Diagnostic and X-raysComprehensive Exam .............................................. 100%(new patient / initial visit)
1 Annual Exam ............................................................ 100%(children under 18 = 2 per year)
1 Emergency Exam .................................................... 100%(problem focused, 1 per year)
4 Bitewing X-rays (1 time per year) ............................. 100%Periapical, First Film ................................................... 100%Periapical, Each Additional Film ............................ 100%Complete Series X-rays or Panorex ...................... 100%(1 every 5 years)
PreventativeChild Prophylaxis (2 cleanings per year) ..................... 100%Adult Prophylaxis (2 cleanings per year) .................... 100%Fluoride (2 per year, no age limit) .................................. 100%Oral Cancer Screenings (2 per year) ......................... 100%Additional Cleanings per year .................................. 15%Dental Sealants ............................................................. 15%
All Other ProceduresFillings and core buildups ......................................... 15%Oral Surgery ....................................................................15%Root Canals .....................................................................15%Crowns ............................................................................. 10%Veneers ............................................................................ 10%Periodontics ................................................................... 10%Dentures and Partials .................................................. 10%Implants ........................................................................... 10%ZOOM!™ Whitening ............................................ $100 OFFInvisalign®, ClearCorrect™, Six Months Smiles™, and Inman Aligner™ *** ............................................. $500 OFF
*The dual plan is for parent/childor husband/wife only.
**The family plan includes family members and children under 18or children who are enrolled in
college full-time until the age of 23.
***An Invisalign, ClearCorrect, Six Month Smiles or Inman Aligner member must remain a plan member for the duration
of treatment to retain discount plan bene�ts.
Plus one-time $99 enrollment fee.
© 2016 N
PI. All rights reserved.
HiTechSmiles.com
Dental $avings Plan
Our Dental $avings Plan is designedto provide greater access to quality dental care at an a�ordable price.It’s a discounted fee schedule for most services,only good at the Center for Advanced Dentistry.
You save on everything from cleanings and �llingsto cosmetic procedures and crowns!
✓ NO yearly maximums✓ NO deductibles✓ NO claim forms✓ NO pre-authorization requirements✓ NO health questions✓ NO pre-existing condition limitations✓ NO one will be denied coverage✓ NO waiting periods (immediate eligibility)✓ FREE consultations
You will not be singled out for rate increases orcancellations. You will not receive a membership card.Your plan’s e�ective date will be on �le with our o�ce.
• 2 Exams per year• 2 Cleanings per year (absence of infection)
Our Dental $avings PlanIncludes the FollowingServices at No Charge:
• Patient’s portion of bill is due the day of service.
• There will be a $50 reinstatement fee if your plan lapses.
• Cannot be used in conjunction with another dental plan or �nancing program such as CareCredit or Lending Club. If 3rd party �nancing is used, the patient will be responsible for all merchant fees.
• No refunds of premiums will be issued at any time if participant decides not to utilize dental plan.
• NON-REFUNDABLE.
Program Guidelines
Please ask one of our friendly front desk team
members for an application or visit our website:
HiTechSmiles.com
Program Exclusions & Limitations
Now WelcomingNew Patients!
Join the Center for Advanced Dentistry's In-House
Dental $avings Plan
Auto Renewal Policy = 5% OFF!Sign up for auto-renewal of your dental savings plan
and receive 5% OFF next year’s premium!Ask our front desk team members how to sign up
for this great o�er!
6916 McGinnis Ferry Road, Suite 500Suwanee, GA 30024
(770) 623-8750Ushma Patel, DMD
Brittany Corbett, DDS
This program is a discount plan, not a dental insurance plan. It cannot be used:
• In conjunction with another dental plan, dental insurance, or �nancing program such as CareCredit.
• For treatment which, in the sole opinion of our doctors, lies outside the realm of their capability.
• For referrals to specialists.
• For hospitalization or hospital charges of any kind.
• For costs of dental care which are covered under automobile medical.
• For services of injuries covered under workers’ compensation.
This plan is only honored at the Center for Advanced Dentistry. It cannot be used at any other dental o�ce.
