The Foutz Family Dental Plan is an annual dental savings plan, allowing non-insured individuals and families to receive quality dental care from Foutz Family Dental at a discounted cost. This in-office plan is NOT dental insurance but an alternative for our patients who want excellent dental health coverage without the barriers of traditional dental insurance. By eliminating the middleman and reducing administrative costs, we can offer the Foutz Family Dental Plan to patients for a very affordable annual membership fee.

 

Benefits of the plan include:
• No deductibles
• No annual maximums
• No waiting periods
• No limitations on pre-existing conditions or replacements
• No pre-authorizations required

 

There’s no ID card and no member number to bring! All your membership information will be kept in your electronic record.

 

ELIGIBILITY: Participants are eligible to receive plan benefits immediately upon payment of the enrollment fee. Children through the age of 13, in the same household, may only enroll in the plan as a dependent of an adult member.

 

ENROLLMENT FEES:
Adult Membership (13 and over) $425
Children (12 and under) $325

 

MEMBERSHIP: Once the annual fee is paid, you will be entitled to the membership program for 12 consecutive months from your enrollment date. Failure to comply with the terms of the plan may result in termination of the plan and forfeiture of any fee paid by the member or third-party.

 

SERVICES INCLUDED IN THE YEARLY MEMBERSHIP:
• 2 routine dental exams
• 1 limited (emergency) examination (does not include After Hours Fee of $250, but the 20% discount does apply making it $120)
• 2 topical fluoride treatments per year
• All necessary recare x-rays including a full mouth series or panorex every 3-5 years.
• 2 routine cleanings or the cost of a simple cleaning towards two periodontal maintenance cleanings (does not include advanced hygiene services such as scaling and root planning or full mouth debridement). If scaling or root planning are necessary, the cost of a routine cleaning will be deducted from the fee for scaling and root planning and the additional cost will be at a 20% discount (up to the 2 cleanings included in the plan annually). Additional cleanings at a 20% discount. These services are valued at over $500 for the average adult patient.

 

REDUCED FEES: All additional dental services are offered at a 20% discount from our usual and customary fees. To receive the discount, payment is due at the time of service, made payable to Foutz Family Dental. If you choose to extend your payment for treatment by paying through CareCredit®, the discount is reduced by 10% due to merchant fees.
PLAN LIMITATIONS AND EXCLUSIONS:
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The Foutz Family Dental Plan cannot be used in conjunction with any other discount, promotion, or insurance plan
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The plan cannot be used for services covered under workman’s compensation or for services covered under any accident or automobile policy.
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This plan is NON-REFUNDABLE and NON-TRANSFERABLE. No refunds or exchange of discounts is offered if the participant decides not to utilize the benefits of this plan.
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Only dental services provided by our office are covered by this plan. Services rendered by specialists are not covered.
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Discounts under this program shall not apply to any treatment started prior to enrollment or after membership expires.
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Plan rates and fees for services are subject to change annually.
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Discounts do not apply to dental products or whitening.
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Excludes Dentures and Implant crowns that need to be made out of our office.

 

My Signature below acknowledges I have read the above, agree to the terms and choose to sign up for the Foutz Family Dental Membership Plan