Healthcare Smile Protection Program

HEALTHCARE SMILE PROTECTION PROGRAM ENROLLMENT AGREEMENT

This Healthcare Smile Protection Program Enrollment Agreement ("Agreement") establishes the terms and conditions under which the Practice provides preventive dental and limited restorative services to the Patient named below through the Smile Protection Program. This Program is a membership-based plan offered by the Practice and is not dental insurance. The Patient acknowledges receipt of the program terms set forth in this Agreement and agrees to comply with payment, scheduling and treatment provisions set forth herein.

Practice and Program Identification

Patient Information

Date of Birth:    Gender:

Mobile Phone:    Email:

Relationship:    Phone:

Insurance Information (If applicable)

Policy Number:    Group Number:

Medical & Dental History

Program Benefits — Covered Services

The Smile Protection Program provides the following benefits, subject to the terms, exclusions, and frequency limits described below. Coverage begins on the Effective Date identified in this Agreement.

One or two prophylaxis (cleaning) visits per 12-month period (as applicable)
Periodic oral examinations (up to two per 12-month period)
Selected intraoral radiographs as indicated
Discounted fees for restorative and emergency services (specify discount):

Exclusions, Limitations, and Non-Covered Services

The Program does not cover cosmetic procedures, elective orthodontics, implants (unless specifically listed), lab fees for prosthetics, third-party referral charges, or services rendered by external specialists. Services required as a result of trauma, medically necessary hospitalization, or conditions not disclosed on this form may be excluded. Frequency limitations and clinical necessity determinations are at the sole discretion of the treating dentist in accordance with professional standards.

Fees, Payment Authorization, and Billing

Membership fees are payable in accordance with the payment schedule below. By enrolling in the Program, Patient authorizes the Practice to charge the designated payment method for initial and recurring membership fees and any non-covered services the Patient elects to receive. Failure to maintain payment will result in suspension or termination of benefits without refund except as provided in the Cancellation and Refunds section.

Payment Frequency:    Payment Method (card/check/ACH):

Term, Renewal, Cancellation and Refunds

Term: The initial term of this Agreement commences on the Effective Date and continues for the initial term selected below. Unless Patient timely cancels, the Agreement will automatically renew for successive terms of equal duration on the renewal date.

Effective Date:    Initial Term (months):

Cancellation: Patient may cancel by providing written notice to the Practice at least days prior to the renewal date. Refunds, if any, are prorated at the Practice's discretion and may be subject to administrative fees.

Authorization to Release Records and HIPAA Acknowledgment

Patient hereby authorizes the Practice to use and disclose protected health information as necessary for treatment, payment and healthcare operations related to Program participation. Patient acknowledges receipt of the Practice's Notice of Privacy Practices and understands rights regarding access to health information.

Authorization Expiration Date:

I acknowledge I have received and reviewed the Practice's Notice of Privacy Practices and authorize the uses and disclosures described above.

Consent to Treatment and Liability

Patient consents to necessary diagnostic procedures and routine dental treatment recommended by the treating dentist as part of participation in the Smile Protection Program. Patient understands that all treatment carries risks and that no guarantee is made regarding results. Patient agrees that the Practice and its personnel shall not be liable for complications arising from undisclosed medical conditions or failure to follow pre- and post-treatment instructions.

I consent to treatment and acknowledge the risks involved as described above.

Acknowledgments and Representations

By signing below, Patient represents that all information provided on this Enrollment Agreement is true and complete to the best of Patient's knowledge; Patient agrees to notify the Practice promptly of any changes. Patient understands the Program is not insurance and that any third-party payments (including insurance) are separate from membership obligations under this Agreement.

I understand this Program is not dental insurance.

Dispute Resolution

Any dispute arising out of or related to this Agreement shall first be submitted to non-binding mediation. If mediation is unsuccessful, the parties may pursue resolution in a court of competent jurisdiction. The parties agree that the Practice may seek injunctive relief for protection of confidential information and patient safety where appropriate.

Additional Patient Instructions

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