AFFDENT® SERVICES
SERVICES
Your dental decisions about your dental care should be between you and your dentist without the interference of a
third party involvement.
Affdent® dental plans have been designed to allow you and your family to receive quality dental care from your own
dentist and hygienist.
TYPE I DENTAL SERVICES
Your Affdent patients will receive a 100% discount for all consultations, exams, basic x-rays including panoramic x-rays, sealants, child fluoride treatments and two basic adult or child prophylaxis cleanings per year. There are no out-of-pocket expenses for Type I Dental Services. Their monthly membership fees will pay all or most of these services over a one year time period.
TYPE II DENTAL SERVICES
Affdent patients will receive a 50% discount off the doctor's private fee-for-service schedule. These services include: composite or amalgam restorations, simple tooth extractions, scaling and root planing, adult fluorides, basic root canal therapy, placing post and crown build-ups, crowns, bridges, inlays, onlays, traditional dentures, partials and any type of transitional partial dentures, (flippers). The 50% out-of-pocket portion is due the day of service and is applied towards the Affdent patient's yearly maximum of $1,250 per year. If the treatment plan exceeds the yearly maximum out-of-pocket of $1,250, then the Affdent patient is required to pay full office fee of any Type II Dental Services rendered up and over the $1,250 yearly maximum.
Any dental services not mentioned in the Type I or Type II Dental Services, will be charged full office fee. For example: Porcelain veneers, teeth whitening, traditional orthodontics, Invisalign or any type of aligner orthodontic therapy, night guards, TMJ therapy, dental implants, implant precision attachments, implant retained crowns, implant retained dentures, complex endodontic therapy, 3-D Cone Beam Radiographs, surgical extractions, gingivectomies, gingivalplasties, crown lengthening surgery, etc.
Committed To Dental Excellence
*The discounts associated with this Dental Plan are available only through this office.
*Monthly membership fees are to be paid for a mini mum twelve (12) month period and are non-refund able. Unless waived by the dentist, membership will automatically renew on the anniversary date and continue thereafter until canceled. I also agree to leave a current credit card number and expiration date on file in case there are insufficient funds in my bank account during the monthly membership withdrawal from my bank account.
*Qualified applicants are defined as a husband, wife and any non-married dependent children, (under the age of
- . Any additional children dependents above the total number of four will have an additional surcharge of $10 per month per dependent/child.
*Fees and plan discounts are subject to change without notice.
*Missed or broken appointments without a 24-hour notice will be charged $25 debited from the yearly maximum remaining balance of $1,250.
*All member out-of-pocket fees are due at time of service. *Membership in the Dental Plan may be ter minated for abuse and failure to pay membership fees or properly billed dental charges. If such a situation occurs, then the credit card number on file will be used to pay the total fees of the remaining months left on the 12-month membership contract. *Affdent®. dental plans are administered solely by this dental office and may be discontinued at the end of any month with or without notice. *Affdent®. dental plans benefits are limited to $1,250 per each covered family member per year. *Prophylaxis is limited to once every six (6) months. A difficult prophylaxis (i.e. heavy smoker stains or heavy plaque and tartar, etc), is subject to a$25 surcharge.
*Fluoride treatments are limited to once every six
- months per member up to the age of 18. months per member up to the age of 18. *Denture relines are limited to once per year. *A denture, partial, crown or bridge placed under this dental plan can be replaced only once during a period of five (5) years. *Any dental procedure in progress or performed before a member’s eligibility period is excluded. Oral surgery is limited only to teeth extractions and the preparation of the mouth for dentures or partials. *This dental plan does not provide benefits for the following dental services: bleaching of teeth, porcelain veneers and lnvisalign orthodontics, traditional orthodontics, TMJ therapy, general anesthesia, conscious sedation, nitrous oxide, prescription medications, dental implants, occlusal adjustments, equilibrations, occlusal guards, night guards, splinting of teeth, full-mouth rehabilitation and altering vertical dimension.
MONTHLY MEMBERSHIP FEES:
Singles Plan
$51/MONTH
Couples Plan
$71/MONTH
Family of Four Plan
$91/MONTH