Discount Plan Application | Products Included: Dental

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Renewal Conditions: By joining a plan, you are authorizing Dentist Friendly to bill your credit card or checking account for the plan you have selected. This charge shall remain in force until you notify Dentist Friendly of request to cancel. By joining, you indicate you have read the terms and conditions of the plan. This plan will automatically terminate at the end of your membership term for the plan you have selected. Termination Conditions: Dentist Friendly reserves the right to terminate plan members from its plan for any reason, including non-payment. Cancellation Conditions: You have the right to cancel within the first 30 days after receipt of membership materials and receive a full refund, less the processing fee, if applicable. FL Residents: You have the right to cancel within 30 days after the effective date. If for any reason during this time period you are dissatisfied with the plan and wish to cancel and obtain a refund, you must submit a written cancellation request. Dentist Friendly will accept and cancel plan memberships at any time during the membership period and will cease collecting membership fees in a reasonable amount of time, but no later than 30 days after receiving a cancellation notice. Please send a cancellation letter and a request for refund with your name and member number to Dentist Friendly, 2810 N Church St., PMB 94917, Wilmington, DE 19802 or fax to: 1-888-589-2393. You may also submit cancellation by email: [email protected]. Dentist Friendly is billing you annually, Dentist Friendly will, in the event of cancellation of the membership by either party; make a pro-rata reimbursement of the periodic charges to the member. Description of Services: Please see the enclosed materials for a specific description of the programs that you have purchased. Limitations, Exclusions & Exceptions: This program is a discount membership program offered by Dentist Friendly. Dentist Friendly is not a licensed insurer, health maintenance organization, or other underwriter of health care services. No portion of any provider’s fees will be reimbursed or otherwise paid by Dentist Friendly. Dentist Friendly is not licensed to provide and does not provide medical services or items to individuals. You will receive discounts for medical services at certain health care providers who have contracted with the plan. You are obligated to pay for all health care services at the time of your appointment. Savings are based upon the provider’s normal fees. Actual savings will vary depending upon location and specific services or products purchased. Please verify such services with each individual provider. The discounts contained herein may not be used in conjunction with any other discount plan or program. All listed or quoted prices are current prices by participating providers and subject to change without notice. Any procedures performed by a non-participating provider are not discounted. From time to time, certain providers may offer products or services to the general public at prices lower than the discounted prices available through this program. In such event, members will be charged the lowest price. Discounts on professional services are not available where prohibited by law. This plan does not discount all procedures. Providers are subject to change without notice and services may vary in some states. It is the member’s responsibility to verify that the provider is a participant in the plan. At any time Dentist Friendly may substitute a provider network at its sole discretion. Dentist Friendly cannot guarantee the continued participation of any provider. If the provider leaves the plan, you will need to select another provider. Providers contracted by Dentist Friendly are solely responsible for the professional advice and treatment rendered to members and Dentist Friendly disclaims any liability with respect to such matters. Complaint Procedure: If you would like to file a complaint or grievance regarding your plan membership, you must submit your grievance in writing to: Dentist Friendly, 2810 N Church St., PMB 94917, Wilmington, DE 19802. You have the right to request an appeal if you are dissatisfied with the complaint resolution. After completing the complaint resolution process and you remain dissatisfied, you may contact your state insurance department.