Rules, Limitations, and Exclusions
- 1. This is a membership plan that offers discounted treatment; it is NOT a form of insurance.
- 2. This membership plan is only valid at Springs Family Dental, 1935 N Union Blvd, Colorado Springs, CO 80909. Services performed outside the office are not covered.
- 3. Membership sign-up fees must be paid in full at the time of registration, and no refunds will be issued once membership has begun. Cash, credit/debit card, and check are the only accepted forms of payment.
- 4. Monthly memberships are paid in advance monthly, the first day of each month, on a month-by-month basis, via automatic credit/debit payment. Enrollment in automatic payment is required.
- 5. In the event of a declined payment, the member's account will be immediately suspended, pending the member updating their payment information and their membership dues paid in full.
- 6. A missed monthly payment will terminate the membership plan, and will be subject to the full sign-up fee to rejoin.
- 7. Members that wish to cancel their plan must submit a cancellation form prior to the 1st of the month. Memberships cannot be canceled by phone or email. Reactivating a canceled plan will be subject to the full sign-up fee.
- 8. Monthly payments may change and you will be provided written notice prior to the billing period.
- 9. Members CANNOT have any other type of dental insurance/coverage. Obtaining other coverage while a member of "Springs Smiles" will immediately result in termination of the membership plan. Previously paid fees will not be refunded.
- 10. All fees for services provided must be paid in full at the time of service unless other arrangements have been made prior to service.
- 11. Periodontal patients MUST sign up for the "Periodontal Plan" and are not eligible for the "Adult Plan." Patients who receive periodontal treatment while on the "Adult Plan" will be allowed to finish their current plan, but will be required to switch to the "Periodontal Plan" upon completion.
- 12. Any additional cleanings, exams, or x-rays over the allowed benefit are provided at our usual fees minus the 15% discount. CBCT's are not included.
- 13. Scaling and root planning is not considered a cleaning and is provided at our usual fees minus a 15% discount.
- 14. Patients who have not previously had a comprehensive exam must complete one before entering a plan.
- 15. Members are responsible for receiving treatment within the allotted timeframe. Unused benefits will not be refunded.
- 16. Failure to show or cancellation of a scheduled cleaning appointment without the required 48-hour notice will count as one of your cleaning occurrences and cannot be made up.
- 17. Products such as toothpaste, toothbrushes, rinses, etcetera are not included.
- 18. Rules, limitations, and exclusions are subject to change without notice.
This Agreement contains the entire agreement between the parties and supersedes any prior written or oral agreements between them concerning the subject matter of this Agreement.
I understand the benefits, limitations, exclusions, and requirements of the membership and I agree to the following: fees for dental services are due as the services are rendered. Failure to comply may result in my being charged the usual and customary fees for those services. A late fee may apply to accounts when there are not sufficient funds available in your account to clear your payment when paying for services and/or monthly fees. I agree to pay any and all costs in collecting all charges including, but not limited to, attorney fees and court costs. Coverage must be continuous. Late fees must be made up for uninterrupted service. Fees are nonrefundable.
By enrolling in an auto-debit contract, you authorize Springs Family Dental to, on a recurring basis, automatically charge the debit or credit card account you specified, for the monthly payments on your auto-debit plan associated with your account, on the billing due date. You understand and acknowledge that Springs Family Dental will initiate transfers/charges pursuant to this authorization not to exceed the amount shown on your Membership Agreement.
If any portion of this agreement is deemed illegal, void, or unenforceable, then the remaining agreement shall remain in effect.
Friendly Staff, Beautiful Smiles,