Delta Dental Patient Direct Application for Membership



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Yes! Please register me in Delta Dental Patient Direct. Mail this form to Delta Dental of New Jersey, Inc.

Delta Dental Patient Direct Membership, P.O. Box 256, Parsippany, NJ 07054. If you wish to pay by Mastercard, Visa, or Discover, visit our website www.patientdirectnj.com to enroll.



Delta Dental Patient Direct

Application for Membership


(THIS IS NOT INSURANCE)
Name ______________________________________________________________________________________

Last First Middle Initial


Address ______________________________________________________________________________________

Street City State Zip Code


Home Phone ( ) Work Phone ( )
E-mail address ____________________________________



ELIGIBLE PERSONS

Complete this box for yourself and all dependents for membership. Attach another application if you have more than four children. (Note: Dependent children are included under a parent's membership only until the end of the membership year in which they attain the age of 23.)



Last Name

First Name

MI

Date of Birth

Sex

M/F


Social Security Number

MO

DAY

YR

Applicant *























Spouse/Domestic Partner























Child























Child























Child























Child























Legal Ward























* Must be 18 years of age or older



Payment enclosed 

 Individual at $66.00 annually

 Family at $96.00 annually

See Terms and Conditions


Make check or money order payable to:

Delta Dental of New Jersey, Inc.



I hereby apply for membership based on the Terms and Conditions attached hereto. I realize that this is not insurance. I understand and agree that dental services provided by Delta Dental Patient Direct network dentists will be at the level of fees described in the attached Terms and Conditions. I hereby accept responsibility for payment of fees. I understand that a Delta Dental Patient Direct dentist must provide services in order to receive the services at the Delta Dental Patient Direct Fee Schedule. I understand that Delta Dental reserves the right to increase the membership fee once per contract year with 30 days advance notice. I acknowledge that dentists' fees under this Program are subject to change and that I will be responsible for the fees in effect at the time of service. I further acknowledge that my membership in the Delta Dental Patient Direct Program will become effective only if approved and services are rendered on or after the effective date of my membership. I certify to the best of my knowledge and belief the information given on this application is complete and true. I understand that my dependents' and my membership may be cancelled without written prior notice if I have included false information. I also understand that such termination will be retroactive to the date of my membership.

Signature ______________________________________________ Date __________________



Delta Dental Patient Direct

Member Terms and Conditions
On behalf of my dependents (if applicable) and myself (sometimes collectively referred to herein as "Members"), I agree to the following:


  1. Delta Dental Patient Direct is not an insurance plan. There are no benefits payable to Members, nor does Delta Dental Patient Direct compensate dentists for services they may render to Members. Delta Dental Patient Direct is not an insurer, guarantor or underwriter of any services provided under the Delta Dental Patient Direct program ("Program") or of any payments to dentists. Members arrange for dental care and for payment directly with the dentist. Members are responsible for the entire cost of the care, and Delta Dental shall in no event be liable for any payment to a dentist accessed under the Program or for the refusal of a dentist to accept the Delta Dental Patient Direct Fee Schedule.




  1. The Program provides Members access to a network of dentists who are independent practicing dentists. Delta Dental Patient Direct dentists are independent contractors in private practice and are neither employees nor agents of Delta Dental and/or its parents, subsidiaries or affiliates. The availability of any particular dentist cannot be guaranteed, and dentist network composition is subject to change without notice.




  1. Delta Dental does not provide dental treatment and is not responsible for outcomes. All dental care is the responsibility of the treating dentist, in consultation with the Member. Selection of the dentist is also the responsibility of the Member and is not based on any representations by Delta Dental.




  1. Delta Dental Patient Direct dentists have agreed to make certain services available to Members at the fee level set forth in the Delta Dental Patient Direct Fee Schedule. I understand that all payments to Delta Dental Patient Direct dentists are due and payable at the time of service, unless another payment arrangement is mutually agreed upon between the Member and the treating dentist. Members shall be responsible for the treating dentist's office policies such as payment for missed appointments or late payments.




  1. In order to receive included services at the Delta Dental Patient Direct Fee Schedule, a Member must present his/her program ID card to the dentist's office at the time of his/her appointment.




  1. Delta Dental Patient Direct may, from time to time, and at its sole discretion, provide Members with access to additional programs that offer access to vision and/or other non-dental services at discounted or special rates. Any such programs are offered by independent persons who are not employees or agents of Delta Dental or its affiliates. Delta Dental does not endorse any such product or services, and the persons providing such products/services are solely responsible for the products/services they provide. Persons providing such programs are not reviewed or credentialed by Delta Dental Patient Direct.




  1. This Program is limited to dental services rendered in the State of New Jersey. Members must reside in the State of New Jersey. Delta Dental may terminate the Program in its entirety without prior notice to Members if necessary to comply with the law.




  1. Delta Dental reserves the right to terminate a Member's participation in the program with 30 days notice, for any reason.




  1. If, for any reason, I am not totally satisfied, I may notify Delta Dental in writing within 30 days of the effective date of membership, and Delta Dental will fully refund my money.




  1. Not all services are reflected on the Delta Dental Patient Direct Fee Schedule. A Delta Dental Patient Direct dentist may bill me for his/her usual fee for services not listed on the Delta Dental Patient Direct Fee Schedule. The usual fee is the fee most often charged and collected by the Delta Dental Patient Direct participating dentist from patients without insurance. The dollar amount specified may not be the only cost incurred in a given treatment because the treatment may require more than one procedure.




  1. No person, other than your eligible dependents and you, are entitled to any rights under the Delta Dental Patient Direct Program, membership is not transferable, and participation in the Program may be terminated immediately in the event that my dependents or I provide access to his/her program ID card (or otherwise provide unauthorized access to the Program) to any ineligible individual.




  1. Eligible dependents under a family program include your spouse /domestic partner, providing you have a certificate of civil union which Delta Dental can request as proof of domestic partnership; and/or one or more of your eligible child dependents. Eligible child dependents include my and my spouse's natural born children or stepchildren, legally adopted children, a child for whom we have legal guardianship and who is wholly dependent upon us for most of his/her support and maintenance, and our foster children. Proof of support or adoption and all other matters pertaining to eligibility, as a dependent child must be submitted to Delta Dental when requested.




  1. Eligible dependent children are included under my family membership (if selected by me) until the end of the contract year in which they attain the age of 23.




  1. A child otherwise defined above but who has obtained age 23 and who Delta Dental determines is incapable of self-sustaining employment by reason of mental or physical handicap or developmental disability shall be considered a child under this program if he/she depends on the participant or the participant's spouse for support and maintenance and had the condition before attaining age 23. Proof of handicap must be submitted to Delta Dental when requested.




  1. This Program does not apply to any dental services or treatment plan, including any work in progress, which had begun prior to the date I notified the Delta Dental Patient Direct dentist of my membership in the Program and presented him/her proof of my membership. Work in progress, prior to joining the program, must be provided by the dentist who started the work. Any procedures performed by a non-participating dentist are not included. Any member accepted for orthodontic treatment must remain a member of Delta Dental Patient Direct for the full duration of their treatment or risk additional charges from their participating orthodontist. Invisalign may not be included.




  1. This Program cannot be used in connection with any dental insurance or benefit coverage, including Delta Dental nor can this Program be used in connection with any other type of insurance, including but not limited to medical and accidental injury insurance. This program does not coordinate benefits with any insurance or benefit programs. Members who have dental insurance are not eligible for the Delta Dental Patient Direct program.




  1. The Delta Dental Patient Direct program is administered by Delta Dental of New Jersey, Inc.




  1. Delta Dental has no liability for providing and does not guarantee dental services nor is it liable for the quality of any dental services rendered.




  1. This Program does not encompass all dental services. Some procedures are not included in the Program. To determine if a particular procedure is included in the plan, the member must contact our customer service agents toll free at

877-TOOTH-07.


  1. Members may sign up once in a 12-month period.




  1. This program is only available if included services are performed by a Delta Dental Patient Direct participating dentist. It is the Member’s responsibility to ensure the dentist is participating in the Delta Dental Patient Direct program even when referred by the dentist to a specialist or to another dentist. Be aware that dental offices participate in various Delta Dental plans. If you call an office you believe is a Delta Dental Patient Direct participating dentist (always use the specific term “Delta Dental Patient Direct” not the general term “Delta Dental’) and that office does not agree, immediately call Delta Dental Patient Direct customer service at 877-TOOTH-07.




  1. Membership is effective the first of the month following receipt and approval of payment. Notification will be through a welcome packet and receipt of ID card(s).




  1. The Delta Dental Patient Direct Fee Schedule is subject to change by Delta Dental and shall not occur more than once per calendar year.




  1. All applicants must be eighteen years (18) or older to register in this program.




  1. Enrolling in Delta Patient Direct gives Delta Dental the right to check if you are currently active in any other Delta Dental product.




  1. By signing the attached application, I acknowledge that I have read and understand the above terms and conditions and agree to abide by them.

All communications to Delta Dental with respect to the Delta Dental Patient Direct program shall be sent to:


Delta Dental of New Jersey, Inc.

P. O. Box 256

Parsippany, NJ 07054

Telephone - 877-TOOTH-07 (877-866-8407)



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