Form

Dental Health Partnership

SINGLE ENROLLMENT FORM

Membership in the Dental Health Partnership (DHP) of Denmon Family Dental operated by Dane J. Denmon DMD is an agreement to provide discounted dental services in exchange for an annual fee. Membership in DHP is an alternative to traditional insurance that can be used for services ONLY with Dane J. Denmon DMD.

Application

DHP Benefits are for a 12 month period of time beginning on the 1st day of the month following the enrollment date and can be renewed annually.

Enrollment Date

Last Name (Primary Applicant)

First Name (Primary Applicant)

Date Of Birth

Address

City

Zip Code

Home Phone (Landline)

By providing your email and cell phone number, you are consenting to receive emails, calls and/or SMS/MMS messages, including automated calls and texts.

Cell Phone (if no cell phone enter home phone)

Individual Plans

Enrollment in Denmon Family Dental and Dane J. Denmon DMD, Dental Health Partnership is an agreement between Primary Applicant and Dentist to provide dental services at the office located at 232 S. German Street Suite A, Dushore, PA.

Primary Applicant must read each line and attest that they understand the DHP terms, conditions and limitations.

Checkbox

All the information in this form is true and I understand that it is a crime to knowlingly provide false or misleading information to a health care provider for the purpose of attaining benefits.

Checkbox

I understand that this DHP is for services performed at Denmon Family Dental and cannot be utilized for services provided by other dentist, dental offices, dental specialist, dental hygenists or dental hospital charges.

Checkbox

I understand that the DHP benefits cannot be used in conjunction with other dental plans or insurances, as well as, for Workman's Compensation or automotive dental or medical coverage.

Checkbox

I understand that covered dental treatments through the DHP are only those which, in the sole opinion of Dane J. Denmon DMD, are within the realm of his expertise. Referrals to dental specialist are not covered under the DHP.

Checkbox

I understand that the annual fee for membership in the DHP is non-refundable, non-transferrable and non-redeemable for dental products or merchandise.

Checkbox

I understand that benefits are for 12 months beginning on date of enrollment and that if benefits are unused during this time, no refunds are issued and benefits cannot be transferred to next year's enrollment and cannot be tranferred to other individuals or or other plan members.

Checkbox

I understand that full payment of the annual fee for primary and secondary applicants is due at the time of enrollment. After enrollment, no refunds are issued if applicant(s) should decide to withdraw from membership. The number of secondary applicants cannot be reduced or changed once enrolled. No pro-rations are offered for less than a 12 month period.

Checkbox

I have read all the terms and conditions of this DHP and enter into this DHP willingly.

By signing here, I attest that I have read and understand all the information provided to me about the DHP offered through Denmon Family Dental and the practice of Dane J. Denmon DMD.

Signature