Healthy Smiles Terms & Services

The Healthy Smiles Membership Plan is not insurance.  This program is offered to individuals and families who do not have insurance, or who choose not to utilize their insurance at our office. Membership Plan benefits are not transferable to another dental practice or dental specialty practice.  Payment is always due at the time of service.

• Membership is for one year beginning on the enrollment date.
• Each additional family membership must reside at the same address and be paid at the time of the initial membership or at renewal time.
• Membership dues for all family members are payable in full upon enrollment.
• Cash, check or credit card payments accepted.
• Care Credit may be used however the 20% discount on dental services will be reduced to 10%
• Membership will automatically renew on the anniversary date unless written request to cancel is received prior to renewal date.
• Member gives permission for Loudoun Dental Smiles to process their credit card on the annual renewal date (1 year from date noted below) unless written request to cancel is received prior to renewal date.
• Annual membership fees may be adjusted annually.
• Member will be informed of any increase in annual membership fee prior to renewal.
• Members are responsible for notifying Loudoun Dental Smiles of any address or contact changes.
• Missed appointment fees are ineligible for the membership discount.
• Membership may be terminated at will by written notice from the patient to Loudoun Dental
  Smiles.
• Loudoun Dental Smiles may terminate the membership by written notice to the patient when terminating the doctor patient relationship or discontinuing the membership program.
• Membership benefits are not transferable, have no cash value and may not be redeemed for cash.
• This is not an insurance plan and is not subject to regulation by the state department of insurance.
• Plan membership cannot be combined with current dental insurance plans.
• No insurance claim will be filed for Members under this plan.
• The plan is for individual use only.  It is not a group benefit plan.
• Payments for additional dental services are the member’s responsibility.
• Additional dental service fee will be based upon the fee at the date of service.
• Payment is due on the date of service to qualify for the discounts detailed above.
• Membership must be current to receive the discount.
• Loudoun Dental Smiles retains the right to interpret the program stipulations.
• It is the member’s responsibility to schedule and keep all appointments offered as part of the Health Smiles Membership Plan.
• Please notify our office at least 48 hours in advance if you must change a scheduled appointment.
• No deductibles, no pre-authorizations, no yearly maximums, no waiting period.
• No exclusions for elective care.

Disclaimer: This agreement does not provide health insurance coverage, including the minimal essential coverage required by applicable federal law.  It provides only the services described herein.  It is recommended that health care insurance be obtained to cover dental services not provided for under this in-office membership care agreement.