Enrollment form dental discount saving program



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Enrollment form

DENTAL DISCOUNT SAVING PROGRAM
Reliant Ins

4501 24 Mile Rd, Suite C

Shelby Twp, Michigan 48316



LAST, FIRST NAME


DATE OF BIRTH



HOME ADDRESS



CITY/STATE/ZIP



EMAIL





PHONE NUMBER


SOC. SEC. NUMBER

SPOUSE’S LAST, FIRST NAME


DATE OF BIRTH



DEPENDENT

DATE OF BIRTH

DEPENDENT

DATE OF BIRTH

DEPENDENT

DATE OF BIRTH



DEPENDENT

DATE OF BIRTH




 $ 119.00 FAMILY  $ 84.00 INDIVIDUAL


Select payment option below:

CASH CHECK VISA MASTERCARD DISCOVER AMER.EXPRESS





EFFECTIVE DATE (MONTH & YEAR) EXPIRATION DATE (MONTH & YEAR)

***COVERAGE EXPIRES 1ST OF MONTH 1 YEAR FOLLOWING EFFECTIVE DATE***

I WISH TO APPLY FOR MEMBERSHIP IN THE RELIANT INS. DENTAL DISCOUNT SAVINGS PROGRAM. I UNDERSTAND THAT PAYMENT WILL BE DUE IN FULL AT THE TIME SERVICE IS RENDERED. THIS IS NOT AN INSURANCE PROGRAM.





SIGNATURE DATE




DENTAL DISCOUNT SAVING PROGRAM

MEMBERSHIP AGREEMENT

MEMBERS AGREEMENT
By submitting the attached Enrollment Form you acknowledge on your own behalf, and on behalf of any family members, that you have read and agree to the following terms and conditions and the other terms and conditions in our Agreement:
1. DESCRIPTION OF PROGRAMS FEATURES:
You are entitled to receive discounts on specified services while an active member in good standing in the Program. We have agreed to make certain services and supplies available to you as a Member in the Program on a “Reduced Fee for Services” basis.
In order to receive Reduced Fee For Services at the discounted rate, you must present your Membership ID card to the Provider before dental services are rendered. To be entitled to the benefit of the Reduced Fee For Services, you must also pay in full for the services received at the time the services are performed. We accept Master Card, Visa, American Express, Discover, Care Credit, cash and check payments.
The Program is not insurance and it cannot be used with insurance. The Program will not reduce deductibles, co-payments or other out-of-pocket expenses for dental services that are covered by insurance. Without limitation, the Program may not be used in conjunction with any insurance program and is not valid for treatments covered by workmen’s compensation, automobile, medical, no-fault, liability or other insurance.
Discounts are not available on any sale or promotional services or items. This program is limited to select referral specialists outside of our office. This program may not be used for hospitalization or hospital charges of any kind.
The Reduced Fee For Services and the amount of the discount are subject to change, modification or substitution from time to time. A current list of Reduced Fee For Services eligible for discount and the amount of the discount are available upon request. You should confirm whether a Reduced Fee Service is available for a discount, the current fee for a particular dental service, and the amount of the discount before receiving any service.
2. MEMBERSHIP TERM:
The initial membership term is 12 months. Your membership will become effective the date you complete and submit the Enrollment Form and pay the fees provided for in the Enrollment Form. Subsequent renewal membership terms are 12 months, renewing the first day of the month of the month of your initial enrollment. Once the initial fee for Membership in the Program (“Membership Fee”) and any enrollment or processing fee is paid and received, a Member will be entitled to receive the then current discount on Reduced Fee For Services for the Membership Term. In the event any of the term or condition of the Agreement is violated, your participation in the Program and your Membership Term may be terminated immediately.
3. RENEWAL OF MEMBERSHIP:
YOU WILL BE NOTIFIED THREE TO FOUR (3-4) WEEKS PRIOR TO THE EXPIRATION OF YOUR MEMBERSHIP TERM.

4. CANCELLATION AND REFUND POLICY:
If you cancel the membership within the first thirty (30) days after joining the program and before you have received any discounted dental services, you will receive a refund of all membership fees. In order to cancel the membership and receive a refund, cancellation request MUST be made in writing and membership ID Card must be returned to us. Cancellations requests made after the first thirty (30) days of joining are not eligible for a refund.
5. MEMBERSHIP PAYMENT/BILLING:
Checks returned as unpaid (NSF) will be assessed a $25.00 service charge. Past due accounts that are not brought current within 15 days of the mailed notice are subject to suspension and possible account termination.
In order for your membership to continue without interruption, your renewal payment must be received one (1) week prior to the expiration date identified in your Enrollment Form. In all events, it is your responsibility to ensure that we have received payment for membership renewal one (1) week prior to the expiration date identified in the Enrollment Form.
6. MEMBER ACKNOWLEDGEMENTS:
Membership in the Program and your rights or duties under this Agreement may not be assigned or delegated by you without our prior express written consent. You agree that you will use your Program Membership only for your personal benefit or for the benefit of the family members identified on the attached Enrollment Form. A violation of this Paragraph may result in immediate termination of the Program Membership.



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