Comprehensive Dental Care Benefit Plan

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Comprehensive Dental Care Benefit Plan

Monroe Family and Cosmetic Dentistry is now offering a Comprehensive Dental Care Benefit Plan to individuals and families who are not covered by traditional insurance. By enrolling in our benefit plan, you will receive dental services from Monroe Family and Cosmetic Dentistry at reduced fees that make sense for today's economy. We care about total dental health and we have made our plans affordable for individuals as well as families to enroll.

Who can enroll?

./ Individuals, spouses, and dependent children under the age of 19

Benefits Q,[a Benefit Plan

./ Unlike traditional dental insurance companies, you do not pay premiums to a large corporation, who then in turn makes dental care decisions based on cost to the company rather that the best dental care possible for you the patient.

./ When you enroll into our benefit plan, you are able to decide for yourself, along with our dental care team, what the best treatment is best for you.

./ Traditional dental insurance only covers a certain dollar amount towards you care per year. This benefit plan has NO yearly maximums on the dental care you receive.

./ By enrolling, an affordable monthly premium entitles you to $20 office visit co-pay, you will receive two complimentary prophylaxis (cleaning), cavity detecting x-rays, and doctor exams.

./ A fee schedule is provided, so you will know what you can expect to pay, rather than an insurance company dictating your financial responsibility based on percentages and loopholes in coverage.

Bendit Premiums

Individual Plan

$10.50/month

Individual + 1 Dependent

$17.50/month

Individual + 2 or 3 Dependents

$24.50/month

**Additional Dependents**

$5.00 each/month

Payment Options

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Plan Terms and Conditions

_ _ _ _ _ _ _ _ _ _ _ _ _----', understand the benefits. Limitations, exclusions, and requirements of the Comprehensive Care Benefit Plan and I agree to the following: I will remain in the plan and pay

membership fees (or a minimum 0(12 months. Payment of less than 12 months of membership fees may

result in my being charged usual and customary fees for all services (included those already provided) and my being charged remaining months fees in a lump sum plus an early termination fee of $150. Membership fees that are paid on a monthly basis are charged on the first of each month and that payment date cannot be changed or negotiated. I understand that a non refundable processing fee of $7 is required for

processing enrollment either on a monthly or yearly basis. Fees for dental services are due as serviced are rendered. Fees for prosthodontic and cast restoration services are due at the preparation/ impression visit. Failure to comply may result in my being charged usual and customary fees for such services. I agree to pay any and all costs in collecting all charges, including but not limited to attorney fees and court costs. I understand that if I default on my payment terms for any reason, my account can be turned over to a collection agency and I win be responsible for the associated fees. Coverage must be continuous. At no point are fees refundable. To terminate plan benefits after the 12 months, I must notify Monroe Family and Cosmetic Dentistry in writing prior to the first ofthe month to avoid membership fees being charged. No refunds are given for partial months. I also understand that this plan is not an insurance plan of any kind.

Dental Limitations and Exclusions

1. Demonstrated non-compliance with recommended course of treatment

2. Services which in the opinion of the attending dentist are neither necessary nor recommended for the patient's dental health

3. Restorations, splints, or other appJiances used to increase vertical dimension or restore occlusion 4. Oral surgery requiring the setting of fractures or dislocations

5. Treatment of malignancies, cysts, or neoplasm or congenital malformations, except congenital anomaly of a tooth or teeth covered from birth

6. Dispensing of drugs not normally supplied in a dental office 7. Hospital benefits for any dental procedure

8. Loss or theft of dental appliances

9. Any procedures of implantation or experimental procedures

10. Service for injuries or conditions which are covered under worker's compensation or employer's liability laws. Services which are provided without cost to the member by an municipality, county or other political subdivision

11. General anesthesia

12. Services that cannot be performed because of the general health, physical, or psychological limitation of the patient

13. Periodontics, endodontics, pedodontics requiring the services of a non participating dentist 14. Those procedures requiring appliances or restorations that are necessary for full mouth

rehabilitation, or to alter, restore or maintain occlusion, including without Jimitation treatment of disturbances of the tempromandibular jOint

15. Fluoride application is limited to dependents under age 19, twice per year 16. Diagnosis and treatment of myofacial dysfunction syndrome

17. Procedures performed in the hospital

18, Orthodontics of any kind are not a covered benefit

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Registration Form

Individual Member Name Individual Member Birthday

Individual Member Social Security Number Covered Dependents and Birthdays

Circle which photo ID you want to use:

Drivers License State ID Passport Military ID

,Check which plan YOU wish to enroll in:

D

Individual Plan: $10.50/ month

D

Individual Plan + 1 Dependent: $17.50/ month

D

Individual Plan + 2 or 3 Dependents: $24.50/ month

Additional Dependents: $5 each/ month- x _ __ Total Yearly Premium

=

$_ _ __

Check Method o(Pavwent:

D

Pay Yearly Premium + a one-time $7 processing fee

D

Pay Monthly Premium with automatic draft from Checking Account/Credit Card + a monthly $7 processing fee

**AII Care Credit transaction will have a $7 processing fee.

**

By signing below, I acknowledge that the information I have provided is true and accurate, and that I have read, understand and have received a copy of the terms of this benefit plan and fee schedule. I understand that this is not an insurance plan, but rather a membership plan.

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Automatic Debitfrom Checking Account Authorization

Terms and Conditions of Authorization to Honor Debits

Drawn by and Payable to Monroe Family and Cosmetic Dentistry.

1. The member enrolling in the dental plan hereby lists and authorizes his/her bank to pay and charge to his/her account, checks drawn by and payable to Monroe Family and Cosmetic Dentistry, provided there are sufficient funds in said account to pay the same upon presentation. The member agrees that his/her bank's responsibility in respect to each such check shall be the same as ifit were drawn on his/her bank and paid personally by him/her. This authority is to remain in effect until revoked by him/her in writing or until his/her bank shall be fully protected in paying such check.

2. He/She further agrees that ifany such check be honored, whether with or without cause and whether intentionally or inadvertently his/her bank shall be under no liability whatsoever even though said dishonor results in the suspension of his/her membership.

3. To the bank named, it is agreed that you may comply with the depositor's request, this company agrees: a) To indemnify you and hold you harmless from any laws you may suffer as a consequence of further actions resulting from or in connection with the execution and issuance of any check, draft, or letter, whether or not genuine, purporting to be executed and received by you in the regular course of business for the purpose of payment, and including any cost or expenses

reasonable incurred in connect therewith. b) In the event that any such check, draft, or order shall be dishoned whether with or without cause, or whether intentionally or inadvertently, indemnify you for any loss even though dishonor results in a suspension of membership. c) To defend at your own cost and expense any action which might be brought by any depositor or any other persons because of your actions when pursuant to the forgoing request, or in any manner arising by reasons of participation in the forgoing plan of statement of collection.

Authorization to Honor Debits Drawn IJy and Pavable to Monroe Family & Cosmetic Dentistry Comprehensive Dental Care Benefit Plan

Bank Name _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ Bank Address _____________________________________

City ___________________ State _____ Zip _ _ _ _ _ _ _ __ Bank Phone Number ___________________________

Bank Routing Number ____________________________ Bank Account Number __________________________

A voided checkfromyour account must be included in order for account to be drafted.

I authorize you to pay and charge my bank account checks drawn by and payable to the order of Monroe Family and Cosmetic Dentistry and agree to remain in the plan for a minimum of one year. Cancellation of banking must be done in writing 30 days prior to the end of the twelve month term.

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Comprehensive Dental Care Benefit Fees

Code

Description

ReguJarFee

Member Fee

EK-Qmilla.t.iaus.

00150 Comprehensive Exam $67 $0

00120 Periodic Exam $38 $0

00140 Limited Exam $62 $0

00180 Comprehensive Perio Exam $68 $0

X-rays

00210 Full Mouth/Complete Series $116 $0

00220 Intraoral Periapical $25 $0 00272 Bitewings- 2 Films $39 $0 00274 Bitewings- 4 Films $52 $0 00330 Panoramic $93 $0 00250 Extraoral Film $58 $0 Prevent.atiye Services. 01110 Adult Prohylaxis $71 $0 01120 Child Prohylaxis $60 $0 01203 Fluoride $33 $0

01330 Oral Hygiene Instruction $65 $0

01351 Sealants $48 $0

01510 Space Maintainer $308 $100

periadcmtal Services

04341 Periodontal Scaling per Quadrant $242 $132

04342 Periodontal Scaling per 1-3 Teeth $119 $92

04355 Full Mouth Oebridement $143 $92

04381 Local Oelivery of Antimicrobials $25 $15

04910 Periodontal Maintenance Cleaning $119 $72

04211 Gingivectomy $287 $148 Res.tcJrative Services 02140 Amalgam-l Surface $108 $75 02150 Amalgam- 2 Surfaces $116 $90 02160 Amalgam- 3 Surfaces $178 $110 02161 Amalgam 4 Surfaces $216 $130

02330 Resin- 1 Surface, Anterior $131 $85

02331 Resin- 2 Surfaces, Anterior $158 $112

02391 Resin- 1 Surface, Posterior $144 $98

02392 Resin- 2 Surfaces, Posterior $188 $119

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Code

Description

ReguJarFee

Member Fee

C,mw.nLBridllJ:.IVt:.ner,:.r S.ervic.es.

D2950 Core Buildup $199 $124

D2740 Crown- All Porcelain $930 $675

D2750 Crown- Porcelain Fused to Metal $895 $625

D2790 Crown- Gold $915 $675

D2930 Stainless Steel Crown, Primary $243 $148

D2920 Recement Crown $89 $49

D6240 Pontic Crown, Bridge $895 $675

D6750 Retainer Crown, Bridge $895 $675

D2962 Veneer $895 $649

Root Canal Theral1.Y Sr,:.rvices

D3110 Direct Pulp Cap $77 $48

D3120 Indirect Pulp Cap $64 $42

D3220 Pulpotomy $182 $98

D3310 Root Canal Therapy, Anterior $695 $446

D3320 Root Canal Therapy, Bicuspid $795 $518

D3330 Root Canal Therapy, Posterior $895 $653

Extr.actiQlJ S.e.rviCJ:,s

D7140 Simple Extraction $115 $92

D7210 Surgical Extraction $196 $148

D7220 Soft Tissue Impacted Extraction $249 $176

D7230 Partially Bony Impacted Extraction $331 $226

D7250 Surgical Root Removal $225 $136

DentureLPartial Services

D5110 Complete Maxillary Denture $1174 $834

D5120 Complete Mandibular $1174 $834

D5130 Immediate Maxillary Denture $1280 $909

D5140 Immediate Mandibular Denture $1280 $909

D5211 Temporary Resin-Based Partial $1152 $502

D5213 Maxillary Metal-Based Partial $1298 $922

D5214 Mandibular Metal-Based Partial $1298 $922

D5225 Maxillary Flex-Based Partial $1152 $807

D5226 Mandibular Flex-Based Partial $1152 $807

CosmeticLQther S.ervices

D9940 Occlusal Guard $367 $260

D9230 Nitrous Oxide $45 $30

D9215 Local Anesthesia $35 $0

D9310 Consultation $235 $49

D9110 Emergency Treatment, Palliative $113 $56

D9440 Office Visit, After Hours $147 $76

BLCH Bleaching Trays W / Sonicare $300 $220

SYRI Bleach Syringe $15 $10