DENTAL, VISION, CHIROPRACTIC, Rx, RN HOTLINE

Aetna Dental Network Access
Outlook Vision Network
CHIROPRACTIC Lifecare of America
HealthTrans Rx Discount
FONEMED 24 Hour Nurse Hotline

Your Cost:
$10.00 PER MONTH for an individual applicant
$20.00 PER MONTH for your entire family

A family plan covers all persons in your household, regardless of actual relationship. To be eligible, all persons listed on the application must be permanent residents of the address listed on the application. There is a one-time, non-refundable registration fee of $15 for the Plan. Please complete the application TODAY so that we may process your request immediately. Plan benefits will begin on the 1st day of the month following receipt of your application. If you require dental services prior to the 1st day of next month, we can, upon request (see form below), put your coverage into effect within 5 business days. (If you have a dental or chiropractic emergency, do not delay treatment. Such a delay could result serious harm or illness, and might result in expenses that exceed any savings realized by waiting for benefits to go into effect.) Once you have completed the application below, we will send you an email message as your confirmation of receipt of your application. The confirmation will contain instructions and telephone numbers that will allow you to make your first appointment without ID cards (they will arrive in 1-2 weeks). DentaSaver.net uses a true Secure Application system powered by Plug'n Pay Technologies to assure the confidentiality of your personal information. This Program is NOT AVAILABLE FOR SALE to residents of Connecticut, Montana, Alaska, New Hampshire and Vermont Who Is Enrolling? (Please select your Dues) Member Only Monthly $10.00 per month Member Only Quarterly $30.00 per quarter Member Only Semi-Annual $55.00 per 6 months Member Only Annual $99.00 per year Family Monthly $20.00 per month Family Quarterly $60.00 per quarter Family Semi-Annual $110.00 per 6 months Family Annual $198.00 per year FEES SHOWN DO NOT INCLUDE $15 ONE TIME ENROLLMENT FEE WE ACCEPT THE FOLLOWING PAYMENT METHODS. Credit Card Types CHECKS ONLINE Please tell us how you found our web site Search Engine Magazine or Classified Friend or Relative Link From Other Site Banner Other Please give us the name of the source Search engine name, magazine, link site, etc.

 

READ CAREFULLY BEFORE YOU APPLY

Plan Information Guide and Plan Identification Card(s) will be supplied via U.S. Postal service. Your request authorizes Comprehensive Insurance Agency, LLC to charge your credit card or debit your checking account for the initial and subsequent payments to start and continue your DentaSaver plan. Comprehensive Insurance Agency, LLC will charge your credit card or debit your checking account as each modal dues payment comes due. You must provide Comprehensive Insurance Agency, LLC 30 days written notice if you wish to cancel your DentaSaver plan. ENROLLMENT FEE A one time, non-recurring enrollment fee of $15.00 will be added to the first modal dues charge that appears on your credit card statement. TOTAL INITIAL PAYMENT CHARGE will be your chosen plan dues PLUS $15.00. All dues thereafter will be the chosen modal dues. I understand that my coverage will not become effective, active and available until the 1st day of the 1st month following submission of my application unless the "Earliest Available" option was chosen on the application. I understand that if I have chosen the "Earliest Available" option, my plan benefits will become available to me 3 business days after receipt of my application by Comprehensive Insurance Agency, LLC, that my credit card or checking account will be billed for a full month regardless of the number of days remaining in the month at the time benefits become available, and that I am not eligible for any benefits, retroactive or otherwise, prior to the actual activation date, regardless of the effective date used for billing purposes. AGREEMENT AND AUTHORIZATION I have read, understand and agree to the terms and conditions above. I authorize Comprehensive Insurance Agency, LLC to sign and charge my credit card or debit my checking account according to the plan and payment frequency I have chosen. I authorize Comprehensive Insurance Agency, LLC the authority to charge my credit card or debit my checking account for all future modal renewal duess as they come due. I will notify Comprehensive Insurance Agency, LLC in writing of my wish to cancel my DentaSaver plan at least 30 days in advance. Exclusions: Specific procedures begun prior to the earlier of the application date or effective date are not covered. Procedures performed by a non-network providers are not covered. You must verify that the provider is in the network when scheduling your appointment. If you agree to these terms and conditions Please Select Your Payment Method: Online Check Credit Card - Debit Card

PLEASE NOTE

Program Participant: Several states have enacted legislation relating to being a "Discount Medical plan Organization" (DMPO). These states require certain disclosures to be to be made regarding your rights and programs to be registered. The package you purchased includes DMPO programs.

The terms and conditions of participation in the DMPO are outlined below:

Disclosures:

• The plan is not a health insurance policy
• 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 Participant is obligated to pay for all health care services but will receive a discount from those health care providers who have contracted with the DMPO. The corporate name and location of the licensed DMPO is: Access One Consumer Health, Inc., 84 Villa Rd., Greenville, SC, 29615
• The DMPO will provide the Participant with a list of participating providers at its website www.accessonedmpo.com or the Participant may call (800) 896-1962 to find a provider. Participants will be able to apply program discounts to all providers of each participating network.. The Participant is obligated to pay the provider for services rendered. In no instance will the DMPO make payments directly to health care providers on behalf of the Participant.

If the Participant or the provider has a complaint regarding the DMPO, then he or she may go to www.accessonedmpo.com or call (800) 896-1962 or write to Access One Consumer Health, Inc., 84 Villa Rd., Greenville, SC 29625. This complaint will be addressed and the Participant or provider will receive a response within 15 days of receipt of the complaint by the DMPO.

The Participant may terminate participation in the first forty-five (45) days after receipt of ID card and receive full refund on any fees or dues paid, less the one time processing fee in states where permitted. After the first forty-five (45) days, the participant may cancel participation at any time. The Administrator must receive notification at least five (5) business days in advance of the next billing cycle for the Participant not to be charged for that billing cycle. If you have canceled at any time after the 45 day period, and you have pre-paid any membership fees, the prepayment will be refunded on a pro-rata basis for months you have not used.

In addition to the above terms and conditions, please note the following:

NOTE TO UTAH RESIDENTS: This program is not covered by the Utah Life and Health Guaranty Association.

NOTE TO WEST VIRGINIA RESIDENTS: If after receiving our response and you are not satisfied with the resolution, you may write or call the West Virginia Insurance Commissioner.

NOTE TO TEXAS RESIDENTS: The (PLAN) will cease collecting membership fees in a reasonable amount of time, but no later than (30) days after receiving a valid cancellation notice. Regulated by the Texas Department of Licensing and Regulation, P.O. Box 12157, Austin, Texas 78711: telephone (800) 803-9202 or (512) 463-5699; website: www.license.state.tx.s/complaints.

This program and the program administrators have no liability for providing or guaranteeing service or any liability for the quality of service rendered.

DMPO programs are currently not available for sale to residents of Connecticut, Montana, Alaska, New Hampshire and Vermont.