Careington Dental Plan Pay By Credit Card Dental Insurance

Step ...
Buy Your Dental Plan

DENTAL PLAN APPLICATION
Credit Card Option

A family membership covers all residents in the household, including children, parents, relatives, significant others, and all permanent residents of the household. There is a one-time registration fee of $15 for the Dental Discount Care Benefit Plan. The registration fee is non-refundable.

Braces, Dentures and Implants Included...
Over 3,000,000 Members & Growing...
20,000+ Dental Offices - Nationwide...
Vision & Prescription Included...

Once you complete this online dental package application, we will send you an email confirmation as your temporary proof of coverage (be absolutely sure your email address is correct once you have entered it) with instructions on how to make your first dental appointment without your id cards (as they will arrive in 10-14 days).

If you experience any difficulty during the application submission process, you can always print the completed application and fax it to us at 310-534-4344.

Please complete the dental application TODAY so we
may process your request immediately.

Step 1 of 4

APPLICATION
Billing Information - Head of Household

First Name:

Last Name:

Mailing (Billing)
Address:

City:

State:

Zip Code:
Example 90001

Phone Number:
Example (310)555-1212

Fax Number:
Example (213)555-1212

E-Mail Address:

Your Enrollment Information

How Many Members
Are You Enrolling:

Any Dependents:

Your Social Security #:
Example 111223333
No Dashes-Spaces

Your Date of Birth:
MM/DD/YYYY
Example 10/15/1950

Sex:

Step 2 of 4

ENROLLMENT INFORMATION
Additional Household Information
If you have additional dependents email us the information after
you receive your confirmation

Please Type Upper - Lower Case Letters

Spouse/Other
Information

Child #1
Information

Child #2
Information

Child #3
Information

First Name

Last Name

Social Security # Example
111223333 No Dashes-Spaces

Date of Birth MM/DD/YYYY
Example 10/15/1950

Sex

Marital Status

Step 3 of 4

PAYMENT INFORMATION
Please Make Your Selection

( ) Individual Membership: The Plan will charge your credit card $95.00 for one year's dental coverage plus a one time $15 enrollment fee (non refundable) which equals a total of $110.00. Then your credit card will be billed once a year thereafter for $95.00 until such time that you provide a 30 day written cancellation notice to the Plan. This is a discount savings of approximately 20% from the monthly bill rate.

( ) Family Membership: The Plan will charge your credit card $145.00 for one year's dental coverage plus a one time $15 enrollment fee (non refundable) which equals a total of $160.00. Then your credit card will be billed once a year thereafter for $145.00 until such time that you provide a 30 day written cancellation notice to the Plan. This is a discount savings of approximately 20% from the monthly bill rate.

Credit Card Type

Credit Card Number:
Please double check the numbers you enter
Visa - MasterCard - Discover - Amex

Credit Card Expiration Date:
(Example 1001 or 100199)

Credit Card Holder Name
As it appears on the Credit Card

Step 4 of 4

AGREEMENT DISCLOSURE
Terms and Conditions

All of the schedule of fee are reduced fees-for-services performed by a participating general dentist. The fee schedule is subject to change without notice. Any procedure not listed is available on a fee for service basis at a 20% discount from the participating provider's fee schedule. Consult with your participating dentist prior to beginning any treatment. Fees do not include lab costs which are the members responsibility. Some services, at the discretion of the general dentist, may need to be referred to a specialist (advanced degree). Please see "Additional Specialty Services." This fee schedule represents the primary plan available in your state.

Additional Specialty Services

Any treatment provided by a participating specialist, if available, in Oral Surgery, Orthodontics, Periodontics, Pedodontics or Endodontics will be charged at a 20% reduction of participating specialist's fees for that particular case. Some specialists may require a consultation visit before treatment is initiated. Discuss each case with specialist prior to beginning any treatment.

Implants and some whitening procedures will not be discounted by all participating CAREINGTON providers. Implants and some whitening procedures will only be discounted if the participating CAREINGTON provider has agreed to discount these procedures as part of their contract. These services will be offered, when applicable, at a 15% discount off of the provider's normal fee.

If the General Dentist's normal fee for any procedure is less than the fee listed on the schedule, the dentist will charge 20% off of their normal fee for that procedure.

Plan Exclusions

(1) Work in progress is not covered. (2) Work in progress after enrollment on the dental plan must be completed before selecting another participating dentist. (3) Any dental procedures performed by a non-participating dentist are not covered. (4) We cannot guarantee the continued participation of any dentist. If he/she leaves the plan, you will need to select another dentist. (5) Not all types of dentists may be available in your area; you may have to travel to receive care from a participating general dentist or specialist. (6) Some providers may charge for missed or broken appointments with no prior notice. (7) Please verify that the dentist is a participating provider when scheduling your appointment. (8) Work in progress prior to enrollment on the dental plan must be completed by the dentist who started the work and is subject to no discount.

AGREEMENT AND AUTHORIZATION

I/We have read, understand and agree to the terms and conditions above. I authorize the Plan and/or assignees limited power of attorney to charge my credit card according to the plan I have selected. I further authorize the Plan the authority to charge my credit card for all future annual renewals as they come due each year. I will notify the Plan in writing of my wish to cancel the membership 30 days in advance.

If you agree to these terms and conditions

Please press the Submit Button ONLY ONE TIME
Wait a few moments for your online confirmation.