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IN-OFFICE DENTAL SAVINGS PLAN A DENTAL PLAN DESIGNED FOR THE UNINSURED… A DENTAL PLAN DESIGNED FOR YOU! A NEW & INNOVATIVE DENTAL PLAN TO HELP YOU RECEIVE AFFORDABLE DENTAL CARE OUR PLAN IS SIMPLE AND STRAIGHTFORWARD. • NO yearly maximums • NO deductibles • NO claim forms • NO pre-authorization forms • NO pre-existing conditions limitations • NO waiting periods WITH THIS DENTAL PLAN YOU ARE ENTITLED TO THE FOLLOWING E ACH YE AR YOUR MEMBERSHIP IS ACTIVE: • Cleanings (D1110) (2 per year)* • X-rays (2 per year) • Emergency Exam and X-ray (1 per year) • Fluoride as needed (no age restrictions) • ALL other dental procedures at a 15% discount off our standard fee. *defined as prophylaxis only, not advanced hygiene services such as scaling and root planning or full mouth debridement ALL THIS ADDS UP TO A COST SAVINGS OF $650 PER MEMBER OR MORE FOR EACH YEAR YOU’RE A MEMBER OF THIS PROGRAM! SO, WHAT’S THE COST TO PARTICIPATE IN THE INOFFICE SAVINGS PLAN? Individual Plan $300 annually Dental Savings Plan for Kids $250 annually You and your family are eligible to save on ALL of your dental services, including: • Tooth Colored Fillings • Dental Crowns • Root Canals • Dentures and Partials • Cosmetic Whitening, and • Almost anything your family’s dental care needs require! PROGRAM DISCLAIMER: THE FEES OUTLINED IN THE DENTAL SAVINGS PLAN OPTION OR OTHER ESTABLISHED FEES BY COOSAW DENTAL ARE NON-REFUNDABLE. ALL PLAN FEES ARE DUE AT THE TIME OF ENROLLMENT. AN ADDITIONAL FEE MAY BE CHARGED FOR ANY MISSED, CANCELLED OR BROKEN APPOINTMENT WITHOUT 24 HOURS PRIOR NOTICE. THIS PLAN IS NONTRANSFERABLE BY PATIENT. THIS PLAN CANNOT BE COMBINED WITH ANY OTHER INSURANCE, DENTAL PLAN, COUPON OR DISCOUNT. FAILURE TO COMPLY WITH THE TERMS OF THE PLAN MAY RESULT IN TERMINATION OF THE PLAN AND FORFEITURE OF ANY FEE PAID BY PATIENT OR OTHER THIRD-PARTY. COOSAW DENTAL RESERVES THE RIGHT TO REFUSE TREATMENT AND/OR TERMINATE THE PATIENT’S PARTICIPATION IN THIS PLAN WITH 30 DAYS WRITTEN NOTICE IF THE PATIENT’S ACCOUNT BECOMES DELINQUENT OR PATIENT IS NON-COMPLIANT. THIS PLAN MAY BE MODIFIED, AMENDED OR CANCELLED AT ANY TIME WITH 30 DAYS WRITTEN PRIOR NOTICE AND MAY BE SUBJECT TO OTHER TERMS AND CONDITIONS. PLAN PARTICIPANTS ARE RESPONSIBLE FOR SCHEDULING THEIR PERIODIC TREATMENTS AND SERVICES NOT UTILIZED AT THE END OF EACH YEAR’S MEMBERSHIP PERIOD ARE NOT CARRIED OVER TO THE FOLLOWING YEAR. ALSO, DISCOUNTS APPLY ONLY TO SERVICES RENDERED BY COOSAW DENTAL AND DOES NOT INCLUDE TREATMENT OR SERVICES PROVIDED ELSEWHERE EVEN IF YOU ARE REFERRED TO A SPECIALIST. WHEN CARECREDIT IS USED, THE AMOUNT OF THE DISCOUNT WILL BE DECREASED BY 10%.