Membership Plan
Healthy Smiles Membership Plan Contract
The purpose of this plan is to offer our patients, without dental insurance, significant savings when the services are paid for in advance. The membership plan is not insurance.
The term of the plan is 12 consecutive months. The plan automatically renews, on the anniversary of the inception date unless written notice is received, in our office, 45 days prior to renewal. The payment is a single renewing annual payment. If you wish for the plan to be billed monthly, automatically, you may discuss this with staff and those arrangements can be made with a credit card on file and an agreement for monthly withdrawal signed in advance.
Indiana law regarding membership programs allows you to cancel and receive a full refund within 30 days of initial sign-up. After the grace period, the plan cannot be cancelled, and no refunds will be given. Services that have been rendered prior to cancellation, will be collected and immediately due at our regular and customary office fees.
Plan benefits may be forfeited if the patient fails to cancel a scheduled re-care appointment within 48 hours of the appointment or fails to appear for scheduled appointments.
Benefits of Our Plan
No deductible, No waiting period (immediate eligibility) No yearly maximum on services.
Limitations and Exclusions
Participants cannot have dental insurance coverage. Services for injuries or conditions which are covered under Worker’s Compensation or other insurance coverage are exempt from our plans. Services that cannot be performed because of the general health, physical, or psychological limitations of the patient are exempt.
Periodontal Disease Limitation
The benefits of this plan are provided to healthy patients who require routine cleanings only. Patients who develop periodontal or “Gum” disease may require a specialized treatment called scaling and root planning. Patients refer to this as a deep cleaning. Scaling and root planning is a therapeutic procedure that is typically administered with anesthetic and destroys harmful bacteria and removes hardened deposits below the gum line. A routine cleaning is a preventative and cosmetic procedure. If you require scaling and root planning, a 15% discount will be given off our usual and customary fees.
Adult Plan
- 2 dental cleanings per year
- doctor exams (1-2 per year)
- diagnostic xrays (bitewings 1xyr pan 1/5yr)
- additional pa xrays as needed
- 1 emergency exam per year (if needed)
- 2 oral cancer screenings
- 1 periodontal screening
Child Plan
- 2 dental cleanings per year
- doctor exams (1-2 per year)
- diagnostic xrays (bitewings 1xyr pan if needed)
- additional pa xrays as needed
- 2 flouride treatments per year
- 1 emergency exam per year (if needed)
- 2 oral cancer screenings
Adult Plan (Periodontal Re-Care)
- Perio maintenance cleanings (3-4 per year)
- doctor exams (1-2 per year)
- diagnostic xrays (bitewings 1xyr pan 1/5yr)
- additional pa xrays as needed
- 1 emergency exam per year (if needed)
- 2 oral cancer screenings
- 2 periodontal screenings
All Plans Include:
15% discount on routine dental services
For patients new to the practice or individuals that have not been seen in the practice for over 2 years, a one-time initial enrollment fee of $50.00 applies.
Our Location
7210 Maplecrest Rd
Fort Wayne , IN 46835