Healthcare Dental & Vision Term

Healthcare Dental & Vision Term

Patient Information

Insurance & Plan Information

Coverage Election

I elect the following coverage for dental and vision services (check all that apply):

Dental Coverage     Vision Coverage

Plan tier (select one or indicate group selection):

Basic    Enhanced    Comprehensive

Terms, Limitations & Exclusions

1. Covered Services: Dental benefits generally include diagnostic, preventive, basic restorative, and major services as defined by the plan. Vision benefits generally include routine eye exams, lenses, frames, and specified services. Coverage is subject to plan specific benefit schedules, deductibles, copayments, frequency limits, and annual maximums.

2. Exclusions: Services not covered include cosmetic treatments, experimental procedures, services for conditions arising from non-covered employment-related activities, services already reimbursed by another payer when not disclosed, and items specifically excluded by the plan documents. Prior authorization is required for certain major dental procedures and specialized vision services.

3. Limitations: Frequency limits (for example, one routine vision exam per 12 months) and age or service-specific restrictions apply. For dental prosthetics and orthodontia, payment may be made on a prorated basis subject to replacement provisions. The patient is responsible for deductibles, copays, coinsurance and amounts in excess of plan maximums.

Coordination of Benefits & Assignment

The patient must disclose all existing dental and vision coverage and other health insurance. Coordination of benefits rules will determine primary and secondary payers. The patient authorizes release of medical and dental records necessary to adjudicate claims and assigns benefits to the provider where permitted. The patient agrees to cooperate with recovery, subrogation or reimbursement actions by the insurer.

Privacy, Authorization & Expiration

By signing below the patient expressly authorizes the release of protected health information to the plan administrator, insurer, and designated third-party claims processors for the purposes of treatment, payment, and health care operations. This authorization includes release of dental and vision records, treatment notes, billing information, and eligibility data. This authorization will remain in effect until revoked in writing except where action has already been taken in reliance on it.

Medical & Dental History (for clinical decision-making)

Billing, Payment & Termination

The patient is responsible for amounts not paid by the plan, including non-covered services, deductibles, copayments and charges exceeding plan limits. The provider may bill the patient for such amounts. The plan or provider may terminate or modify coverage in accordance with plan provisions; termination does not relieve the patient of obligations for services rendered prior to termination.

Dispute Resolution

Any dispute arising under this agreement, except claims for urgent injunctive relief, will be submitted to confidential arbitration in accordance with the chosen arbitration rules of the plan administrator or, if no rules are designated, generally accepted commercial arbitration procedures. Judgment on the award may be entered in any court of competent jurisdiction.

Representation, Consent & Certification

By signing this document the undersigned represents that the information provided is true and complete to the best of their knowledge, that they are authorized to enroll for coverage or to act on behalf of the enrollee, and that they consent to the terms, disclosures and authorizations contained herein. The patient understands they may revoke authorizations in writing except to the extent actions have already been taken in reliance on them.

Sign Now