Standard Keystone Dental Center Wellness Plan Disclosure

Description of Services and Disclosure Form

The following is a description of the Standard KDC Wellness Plan available to you and your household members through Keystone Dental Center. This description completely describes the plan and your rights under the plan, and if you choose to enroll it is your contract with Keystone Dental Center.

We have a special Periodontal Plan that is just for periodontal patients. Periodontal patients cannot apply for the Standard Plan. We may request that patients finish their current plan and switch to the Periodontal Plan if their oral health changes.

1. Contact Information. The full name of the plan is Keystone Dental Center Wellness Plan. Keystone Dental Center is located at 4118 Austin Bluffs Pkwy, Colorado Springs, CO 80918. Plan remains in effect of address changes in the future.
2. Type of Plan. This is a discount fee plan, THIS IS NOT INSURANCE. By paying an annual enrollment fee to Keystone Dental Center, you (and if applicable your eligible family members) will be entitled to receive dental services at reduced rates as described further.
3. Definitions. As used in this Description, eligibility means you or your household members’ right to receive dental services at reduced rates. Eligible family members means any family member currently living at the same address as the initial enrollee. Network Dentist means Dr. Daniel Lamb at Keystone Dental Center which is the dental office agreeing to provide services at the reduced rates set forth in this description. Specialist services are periodontics, endodontics, orthodontics, and oral surgery. A specialist is a dentist who performs only a specialist service.
4. Choice of Dentists. At this time there is one dentist which is Daniel D. Lamb D.M.D
5. Scope of Eligibility. You can select eligibility for you alone, for you and your spouse, or for you and any eligible dependant family members.
6. Commencement of Services. Once you have read through this Description, you should complete the form in the office and submit it to be enrolled . Payment may be made by check, cash or credit card. Once your Enrollment Form and fees are received and processed, Keystone Dental Center will provide you an identification card. If you elect services for your eligible family members they will receive identification cards as well. You must present your identification card to your Network Dentist before you receive treatment. You will be enrolled as soon as your enrollment fee is paid in full. If you have enrolled at a Network Dentists office you can receive discounted services immediately even though you have not received your Identification Card(s).
7. Term and Termination of Services. You and your eligible family members’ right to receive services will continue for a period designated by Keystone Dental Center, starting from the time Keystone Dental Center receives your initial enrollment fee in full. The termination date will appear on your identification card, and will end on midnight on that date. Your right to receive services at the discounted fees described in this plan will end at the expiration of your term unless you are re-enroll as described in Section 8 below
8. Enrollment Renewal. You can renew your right to receive discounted fee services for an additional year by paying an annual re-enrollment fee to Keystone Dental Center before your initial eligibility terminates. Keystone Dental Center may contact you thirty (30) days prior to the expiration of eligibility but is not responsible for your reenrollment. Upon re- enrollment you (and if applicable your eligible family members) will receive new identification cards. The same procedure will be used to re-enroll for succeeding years. Other than payment of the required re- enrollment fee, there are no conditions or restrictions on your right to re-enroll.
9. Cancellations. Once you have paid your enrollment fee, the plan is in effect for one year and may not be cancelled. It is your choice as to access any services.
10. Processing and Enrollment Fees. Applicable enrollment fees for the initial year of services are as follows: Primary individual: $399.00 Additional household members added to the plan: $399.00 each. Re-enrollment fees for years after your initial year of services may change, but you will be notified as to those changes. Currently you will pay the initial enrollment fee through your preferred payment method, cash, check or credit card, and fill out the enrollment form. Payment must be paid in full before eligible for benefits.
11. Services provided by KDC Wellness Plan. The enrollment fee allows patient to be eligible for the following: (A.) Comprehensive new patient exam, one time and/or periodic exam, twice per year (D0150 or D0120) (B.) Needed x-rays (C.) Velscope once per year (D0431) (D.) Basic (Prophylaxis) dental cleaning with periodontal measuring, (D1110 or D1120) up to twice per year (E.) Consultations for any dental service (F.) Topical application of fluoride varnish twice per year. (D1206). (G.) Discount of 20% on additional dental services not included in the services covered by the enrollment fee. Please note that these are the fees currently in effect. Keystone Dental Center reserves the right to change the fees at any time, and any new fees will apply to all dental services received by you or your family members.
12. Other Charges. There are no copayments, deductibles, or other fees for the discounted services that you or your eligible family members receive.
13. Limitations and Exclusions. The following is a complete list of all limitations and exclusions under this Plan: DENTAL: (A.) Discounts for prescription drugs and over the counter drugs are not provided. (B.) Basic (Prophylaxis) dental cleaning is limited twice per scheduled year of your benefits plan. (C.) Limited exams (D0140) (D.) Demonstrated non-compliance with recommended course of treatment. (E.) Services which in the opinion of the attending dentist, are neither necessary nor recommended for the patient’s dental health. (F.) If you are a current patient with an outstanding balance, then the balance must be paid or arrangements made prior to receiving services included in the Wellness Plan, as to not incurred more cost. (G) Loss or theft of dentures or bridgework. (H.) All porcelain crowns/bridges may be replaced if needed in less than a 5 year period, at no cost; as long as patient has been maintaining their regular dental visits; meaning preventive cleaning, x-rays, fluoride and exams twice yearly. (I.) Services that cannot be performed because of the general health, physical or psychological limitations of the patient. (J.) Additional treatment for gum disease such as Scaling and Root Planing (D4341 and 4342) Full Mouth Debridement (D4355) and Periodontal Maintenance (D4910) is not part of the Standard KDC Wellness Plan. Periodontal patients may enroll in the Periodontal KDC Wellness Plan. The Periodontal Plan includes periodontal maintenance. The Standard KDC Wellness Plan is for non-periodontal patients only. The new procedure of scaling in the presence of generalized inflammation (D4346) is also not included in the Standard KDCWP but may be used with an added $20 fee (see paragraph below for more details). (K.) Electric toothbrushes for sale. (L.) Consumables listed but not limited to mints, gum, toothpaste, mouth rinse, nasal spray etc. (M.) Keystone Dental Participants cannot use other dental coverage in conjunction with the Keystone Dental Wellness Plan. Health Savings accounts may be used as long as the plan allows it. (N.) Vivos (O.) 3D Imaging (P.) Any orthodontic treatment (Q.) All products. For procedure D 4346: This is a new procedure code allowing for the patient to receive an intermediate type of dental cleaning contingent upon the status of their oral health. This procedure is needed and performed based upon the removal of plaque, calculus, and stain from above and slightly below the gum line, in the presence of moderate to severe generalized gingivitis/ inflammation. Since this procedure is more extensive there is a extra $20 fee. You may use this as one of your prophylaxis cleanings with the added $20 or you may use this as a separate cleaning for a discounted rate of 20% off the standard fee.

14. Your Responsibility for Payment of Fees. If dental treatment is received, payment is due in full at time of services. Other financial arrangements may be made to cover the cost of treatment, but must be determined prior to treatment. Options for payment in full may be made with cash, check, or credit card. Care Credit and Lending Club may also be used in conjunction with the Standard KDCWP for treatment. Please ask any of the staff members if you have further questions.

15. Confidentiality. Each Network Dentist and Keystone Dental Center itself is required by law to keep your personal healthcare information confidential. No such information can be released except with your consent or as expressly authorized by law (HIPPA).

IF YOU COMPLETE AND SUBMIT THE ENROLLMENT FORM, YOU AGREE TO COMPLY BY ALL OF THE TERMS AND CONDITIONS IN THIS DESCRIPTION.

PRINT NAME: ______________________________________________

SIGNATURE: ______________________________________________

Date: ______________

If enrollee is under 18 years of age, signature of parent/guardian must be enclosed:

Parent/Guardian _______________________________________