MASSILLON SMILES DENTAL PLAN
WHAT IS THE MASSILLON SMILES GOLD PLAN?
The MASSILLON SMILES GOLD PLAN is an annual plan with reduced fees that has been developed to deliver quality dental care service to families like yours that do not have access to dental insurance. Our office offers the convenience of extended hours, plus the individualized attention of private care.
WHERE ARE SERVICES OBTAINED?
Services for this plan are offered at our office only, which is located at 711 Lincoln Way East in Massillon, Ohio.
HOW DO I RECEIVE CARE?
After your membership is effective simply call the dental office for an appointment. Our office offers treatment hours (calls taken beginning at 8:00AM daily):
WHO IS ELIGIBLE?
You, your spouse and any dependent children under the age of 19 or full-time students up to age 23 years of age (proof must be provided).
WHEN WILL BENEFITS BEGIN?
Benefits will begin immediately. This is an annual plan members will remain in the plan for a minimum of 12 months.
WHAT IS THE ANNUAL COST?
WHAT ARE THE BENEFITS?
Unlike a conventional insurance plan there are no deductibles and no yearly maximums. You will receive:
2 Healthy dental cleanings* per year - NO ADDITIONAL CHARGE
2 Routine dental examinationsper year - NO ADDITIONAL CHARGE
Routine x-rays as prescribed by the doctor - NO ADDITIONAL CHARGE
A reduction of 20% off the regular office fee for any additional treatment needed.
A $20 fee for problem oriented office visits
*A dental prophylaxis performed on transitional or permanent dentition that includes scaling and/or polishingprocedures to remove plaque, calculus, and stains from the coronal (crown) of the tooth.
The MASSILLON SMILES GOLD PLAN is NOT a dental insurance policy and does not make payments directly to the provider. It is the responsibility of the members to pay for all dental services from their provider based on the reduced fee schedule. All payments are made directly to the dental office at the time treatment is performed. You should discuss all future payments and costs before future appointments are made.
How To Join
Fill out the attached enrollment form; include your check or credit card information and the number of any eligible family members that will be joining the plan. Coverage will become effective on the date payment is received.
LIMITATIONS & EXCLUSIONS
1. Demonstrated non-compliance with the recommended course of treatment.
2. Services, which in the opinion of the attending dentist are neither necessary nor recommended for the patient’s health.
3. Restorations, splints or other appliances used to increase vertical dimension or to restore occlusion.
4. Any service you are referred out of the office for; Periodontics, endodontics, and oral surgery.
5. Congenital malformations, except congenital anomaly of a tooth or teeth covered from birth.
6. Dispensing of drugs not normally supplied in the dental office.
7. Hospital benefits for any other dental procedure.
8. Loss or theft of dentures, bridges or crowns.
9. Services for injuries or conditions, which are covered under Workers’ Compensation or Employer’s Liability Laws.
10. Services that cannot be performed because of general health, physical or psychological limitations of the patient.
11. If patient should become covered by a traditional dental plan this plan becomes null & void with no refund of the fees.
SERVICE FOR THIS PLAN AVAILABLE AT:
General Dentistry In Massillon
711 Lincoln Way East
Massillon, Ohio 44646
PROVIDERS FOR THIS PLAN ARE:
Shaun P. Doherty D.D.S
Dan Paulus D.D.S
Last Name __________________________First___________________________ MI ______
Home Address ______________________________________________________________
City ____________________________ State _________________ Zip _________________
Home Phone ___________________________ Work Phone __________________________
Birth date _____/_____/_____ Employer __________________________________________
List Covered Dependents
Name Birth date Relationship
Please read and sign below:
I understand the benefits, limitations, exclusions and requirements of the Massillon Smiles Dental Plan and I agree to the following.
1. I will remain in the plan and pay membership fees for a minimum of 12 months.
2. Payment of less than 12 months membership fees may cause me to be charged the usual and customary fees for all services (including those already provided) and my being charged for the remaining months fees in lump sum.
3. Fees for dental services are due when services are rendered.
4. Fees for prosthodontic and cast restorations are due at the preparation/impression visit. Failure to comply may result in my being charged usual and customary fees for such services.
5. I agree to pay any and all costs in collecting all charges, including but not limited to attorney fees and court costs.
Signature _______________________________________ Date___/___/____
To enroll by mail complete the above form, select your payment type below and and return to the office.
Annual Payment Amount enclosed $_____________
______Visa / MasterCad / Discover / American Express
CARD #___________________________________________ EXP Date ______________________ CVW _____________
Authorized Cardoholder Signature_______________________________________________
Mail this form to:
Massillon Smiles Gold Plan
711 Lincoln Way East
Massillon, Ohio 44646