Discount Medical Plan Application | Products Included: Dental

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View Terms and
Membership Agreement

Membership Type *

Your Name *
Your Legal First & Last name
Your E-Mail Address *

to you at this address
Member Date of Birth *
*We do not need additional family members' birth dates. Only the primary.
Primary Member Name
The name you would like printed on your Membership Card. Or, if you are signing up for someone else, enter their name here.
List Family Members
If you selected the family plan above then enter the additional family members.
Referred by
If a friend or family member referred you make sure to give them credit!
Coupon
Dentist Last Name
(Optional)
Enter Broker/Office Code
Leave empty for none.
If you received materials from your employer, broker, friend or family enter the code here.
ADDRESS INFO





CREDIT CARD INFO
Credit Card Type *
please select one
Cardholder Name *
cardholder first and last name, exactly as
shown on the card
Credit Card Number
for example: 1111-2222-3333-4444
Card Expire
Select card expiration date - month and year
Credit Card Code
The "Card Code" is a three- or four-digit security code
that is printed on the back of credit cards in the card's
signature panel (or on the front for American Express cards).
Phone *
enter phone number in the following
format: 999-999-9999
SHIPPING ADDRESS
it's only required if different than address above
Name
Address
City
State
Zip

I have read the Terms and Conditions and wish to purchase the Discount Medical Plan.

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Terms and Conditions

The plan is not insurance. The plan provides discounts at certain health care providers for medical services. The plan does not make payments directly to the providers of medical services. The plan member is obligated to pay for all health care services but will receive a discount from those health care providers who have contracted with the discount plan organization. Discount Medical Plan Organization and administrator: Careington International Corporation, 7400 Gaylord Parkway, Frisco, TX 75034.

TERMS & CONDITIONS

Renewal Conditions: By joining a plan, you are authorizing American Sterling Dental Plans DBA DentaCard to bill your credit card or checking account for the plan you have selected. This charge shall remain in force until you notify DentaCard of request to cancel. By joining, you indicate you have read the terms and conditions of the plan. This plan will automatically terminate at the end of your membership term for the plan you have selected.

Termination Conditions: DentaCard and Careington International Corporation (Careington) reserves the right to terminate plan members from its plan for any reason, including non-payment.

Cancellation Conditions: You have the right to cancel within the first 30 days after receipt of membership materials and receive a full refund, less the processing fee, if applicable. FL Residents: You have the right to cancel within the first 30 days after the effective date. If for any reason during this time period you are dissatisfied with the plan and wish to cancel and obtain a refund, you must submit a written cancellation request. DentaCard will accept and cancel plan memberships at any time during the membership period and will cease collecting membership fees in a reasonable amount of time, but no later than 30 days after receiving a cancellation notice. Please send a cancellation letter and a request for refund with your name and member number to DentaCard at 6150 Parkland Blvd Ste 250, Mayfield Heights, OH 44124 or fax to: 1-888-339-5418. You may also submit cancellation by email: contact@dentacard.com. DentaCard is billing you annually, DentaCard will, in the event of cancellation of the membership by either party; make a pro-rata reimbursement of the periodic charges to the member.

Description of Services: Please see the enclosed materials for a specific description of the programs that you have purchased.

Limitations, Exclusions & Exceptions: This program is a discount membership program offered by Careington. Careington is not a licensed insurer, health maintenance organization, or other underwriter of health care services. No portion of any provider’s fees will be reimbursed or otherwise paid by Careington. Careington is not licensed to provide and does not provide medical services or items to individuals. You will receive discounts for medical services at certain health care providers who have contracted with the plan. You are obligated to pay for all health care services at the time of your appointment. Savings are based upon the provider’s normal fees. Actual savings will vary depending upon location and specific services or products purchased. Please verify such services with each individual provider. The discounts contained herein may not be used in conjunction with any other discount plan or program. All listed or quoted prices are current prices by participating providers and subject to change without notice. Any procedures performed by a non-participating provider are not discounted. From time to time, certain providers may offer products or services to the general public at prices lower than the discounted prices available through this program. In such event, members will be charged the lowest price. Discounts on professional services are not available where prohibited by law. This plan does not discount all procedures. Providers are subject to change without notice and services may vary in some states. It is the member’s responsibility to verify that the provider is a participant in the plan. At any time Careington may substitute a provider network at its sole discretion. Careington cannot guarantee the continued participation of any provider. If the provider leaves the plan, you will need to select another provider.

Providers contracted by Careington are solely responsible for the professional advice and treatment rendered to members and Careington disclaims any liability with respect to such matters.

Complaint Procedure: If you would like to file a complaint or grievance regarding your plan membership, you must submit your grievance in writing to: Careington International Corporation, P.O. Box 2568, Frisco, TX 75034. You have the right to request an appeal if you are dissatisfied with the complaint resolution. After completing the complaint resolution process and you remain dissatisfied, you may contact your state insurance department.

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