The Discount Dental Programs, Inc. Dental Plan is NOT INSURANCE. Members pay the dental provider at the time of service. The discounts are authorized by separate contracts with the providers. If the Member has other health care coverage, the discount benefits may be covered by an HMO or insurance. Members may be eligible for reduced cost or free programs provided by the government. The credentials of the dental professionals providing services have been verified. Discount Dental Programs, Inc. does not guaranty the quality of services or products offered by individual providers. Members shall have no recourse against Discount Dental Programs, Inc. with respect to the services provided by American Dental Group, P.A. Complaints regarding professional services should be directed to the appropriate dental licensing authority in Florida. Membership benefits are limited to the discounted fees as itemized in the Schedule of Fees provided to you when performed by a dental professional at American Dental Group, P.A. Fees are subject to change on an annual basis.

A membership may be cancelled upon written notice postmarked within 30 days of its acceptance for a refund of the initial enrollment fee, less $50. After membership has been in effect for 30 days, the Member may not cancel membership until the expiration date of the initial term of the membership. Unless Discount Dental Programs is advised in writing at least 30 days in advance of the expiration of the initial or subsequent then current term of the membership, said membership shall be renewed for another year at the renewal rates cited on the Application by automatic charge to the member’s credit card or bank account, which ever payment method was initially selected for renewal payments. The membership of any Member may be revoked and cancelled by Discount Dental Programs, Inc. if such Member does not comply with the policies of Discount Dental Programs, Inc. or the provider, including by reason of failing to make prompt payment for any procedure, for failing to pay any cancellation fee for missing an appointment, for failing to pay any fee when due or for providing false or misleading information to Discount Dental Programs, Inc. or the provider. In such cases, the Member will not receive any refund upon cancellation, and if such Member is part of a Family Plan, then Discount Dental Programs, Inc. shall have the right to revoke and cancel the membership of all Members of such family. Immediately upon any cancellation of membership, whether by the Member or by Discount Dental Programs, Inc., all benefits shall cease.

Provision of Credit Card or Bank Account numbers by applicant shall constitute approval to charge said accounts in the absence of applicant’s signature until such signature is secured in person.

New Members are subject to acceptance by Discount Dental Programs, Inc. Discount Dental Programs, Inc. may refuse to accept any new Member in its discretion for any reason not prohibited by law. For purposes of the discounted membership fee for additional family members, family members include spouses and children 18 years of age and younger living in the same household as the primary member.

In the case of any dispute between the Member (and/or any additional family member) and Discount Dental Programs, Inc. which has not been resolved through negotiation between the parties, such dispute shall be settled and determined through arbitration in accordance with the Rules of Arbitration of the American Arbitration Association (“AAA”). Any arbitration pursuant to this agreement shall be held in Collier County, Florida, and shall be conducted by a single arbitrator to be selected by other arbitrators, one of whom shall be selected by each party. The written decision of the arbitrator so selected shall be binding, final, and conclusive on the parties. Judgment on the award rendered by the arbitrator may be entered in any court having jurisdiction thereof. The fees and expenses of arbitration shall be part of the award. The prevailing party in any arbitration shall recover its expenses and costs including reasonable attorney’s fees from the other party.

One or more of the owners of Discount Dental Programs, Inc. may include one or more of the owners and/or dental professionals of American Dental Group, P.A. However, American Dental Group, P.A. does not pay any fees or other consideration to Discount Dental Programs, Inc. to participate in the discount dental plans sold by Discount Dental Programs, Inc. and does not share its fees for professional services with Discount Dental Programs, Inc.

The undersigned Member(s) acknowledge(s) and agree(s) to the foregoing and agree(s) that personal & medical information on any of the members covered by this Application may be shared by the American Dental Group with Discount Dental Programs, Inc. (Spousal & child members 18 years old must sign below. A parent’s signature below shall be on behalf of any minor children under 18 years of age covered by this Application). Signatures below to be secured upon first visit to American Dental Group if not sooner secured.

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