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FirstDentalChoice.com
Dent-All Plan, Inc.—Texas
Discount Program Application

TEXAS RESIDENTS ONLY

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All Plan prices are for Individuals including immediate family and dependents at no extra cost. Immediate family are those individuals identified as dependents on your IRS Tax Forms

Guarantee (Please see complete listing of Disclosures, Terms and Conditions at the bottom of this page)

A member who cancels the membership not later than the 30th day after the date the member joins the discount health care program is entitled to a refund of all membership fees paid to the discount health care program other than money paid as a nominal one-time enrollment fee or money paid by the member to a provider for health care services or products received. Member can cancel at anytime for a pro-rated refund after the first 30 days.

Select a Plan
Plan Monthly Yearly
Plan 1 Vision and Prescription Only $7 $84
Plan 2 Dental Only $9 $108
Plan 3 Dental and Vision Only $12 $132
Plan 4 Dental, Vision, and Prescription $15 $168
SUBTOTAL
Plus Registration Fee
$25.00
TOTAL
All Registration Are Assessed a ONE-TIME NON REFUNDABLE REGISTRATION FEE of $25
Enrollee Information
First Name:
Last Name:
StreetAddress:
City:
State:
ZipCode:
Home Phone:
Work Phone:
Email Address:
Social Security Number: (optional)
Spouse Name:
Spouse Sex:
Spouse Age :
How did you hear about us?:
List the name, sex and age of all of your Dependents
Example: Johnny Smith, Male, 12





Payment Information

Please provide payment, online, with one of the following :

You may pay annually by credit card only.
You may pay monthly by bank-draft electronic check only.

Annual Payment by Credit Card
Name as it appears on the card:
Credit Card Number:
Expiration Date (mm/yy):
Monthly Payment by Electronic Check
(AUTOMATED CLEARING HOUSE -ACH / BANK DRAFT AUTHORIZATION)
Name That Appears on Bank Account:
Routing Number:
Account Number:

Check this box if you have read, understand and agree to the statement above.

All new members must read and check below:
MSofA Dent-All program is NOT an insurance program, and that I am responsible for paying the medical providers promptly for all services received when accessing MSofA Dent-All networks and I agree to abide by the Member Terms and Conditions. Neither MSofA Dent-All nor the networks accessed are responsible for the outcome of the medical care received or the ultimate cost of that care. Participate in the MSofA Dent-All program for one (1) year at a time. All renewals may be charged to my account without further notice. Submit a cancellation notice thirty (30) days prior to my renewal date. If notice is received after this date, a pro-rated refund will be issued. May cancel at anytime.

Check this box if you have read the statement above.
Name of person Authorizing this transaction:
 

To submit this application, press the Submit button below. Press Reset to clear all fields.

Disclosures. - Please see complete Disclosures, Terms and Conditions below and print this page for your records.

  • This is NOT insurance.

  • This discount card program contains a 30-day cancellation policy.

  • Member shal receive a full refund of membership fees, excluding registration fee, if membership is cancelled within the first 30 days. Member may cancel at any time.

  • Pharmacy discounts are NOT Insurance, and are NOT Intended as a Substitute for Insurance. (MT only)

 

Print this page for your records.

MSofA Dent-All Plan, Inc.

Disclosures:

  1. THIS PLAN IS NOT INSURANCE.
  2. THIS IS NOT A MEDICARE PRESCRIPTION DRUG PLAN.*
  3. The plan provides discounts at certain health care providers for medical services. The range of discounts will vary depending on the type of provider and service.
  4. The plan does not make payments directly to the providers of medical services.
  5. Plan members are obligated to pay for all health care services but will receive a discount from those health care providers who have contracted with the discount medical plan organization.
  6. Before purchase, you may access a list of participating health care providers at this website. Upon request the plan will make available a written list of participating health care providers.
  7. You have the right to cancel within the first 30 days after receipt of membership materials and receive a full refund, less a nominal processing fee.
  8. For Dent-All Nationwide members: Discount Medical Plan Organization and administrator: Careington International Corporation, 7400 Gaylord Parkway, Frisco, TX 75034; phone 800-441-0380.
  9. The program and its administrators have no liability for providing or guaranteeing service by providers or the quality of service rendered by providers.

 

Complaint Procedure: If you would like to file a complaint or grievance regarding your plan membership, you must submit your grievance in writing to: Member Services, MSofA Dent-All Plan, Inc.-Texas, P. O. Box 1418, Tomball, TX  77377-1418.  MSofA Dent-All Plan, Inc.-Texas  shall acknowledge a complaint in writing within 5 business days and shall investigate a complaint and provide the complainant with the results of its investigation not later than the 30th calendar day after the date we receives the complaint.  Upon resolution the member is contacted in writing to be advised of the decision.  The member is again advised that he/she may file a written appeal up to thirty (30) days following receipt of the resolution.

Note to Texas Consumers: Regulated by the Texas Department of Licensing and Regulation, P.O. Box 12157, Austin, Texas 78711; telephone 1-800-803-9202 or (512) 463-6599 website: www.license.state.tx.us/complaints.

The program and its administrators have no liability for providing or guaranteeing service by providers or the quality of service rendered by providers.

TERMS & CONDITIONS

The MSofA Dent-All Plan, Inc.-Texas plan IS NOT INSURANCE.

Renewal Conditions: By joining a plan, you are authorizing MSofA Dent-All Plan, Inc.-Texas to bill your credit card or checking account for the plan you have selected. This charge shall remain in force until you notify MSofA Dent-All Plan, Inc.-Texas in writing of its cancellation. By joining, you are agreeing to the terms and conditions of the plan and adopting it for a minimum of one year. This plan will automatically renew at the end of your membership term on an annual basis, and your credit card or bank account will be automatically charged or drafted for the appropriate amount.

Termination Conditions: MSofA Dent-All Plan, Inc.-Texas reserves the right to terminate plan members from its plan for any reason, including non-payment.

Cancellation Conditions: You have 30 days from the date you join to use the plan risk-free. If for some reason within 30 days you are dissatisfied with the plan and wish to cancel and obtain a refund of any membership fees paid, please send a cancellation letter and a request for refund with your name and member number to Member Services, MSofA Dent-All Plan, Inc.-Texas, P. O. Box 1418, Tomball, TX  77377-1418. If MSofA Dent-All Plan, Inc.-Texas is billing you by monthly bank draft or annually, MSofA Dent-All Plan, Inc.-Texas will, in the event of cancellation of the membership by either party, make a pro-rata reimbursement of the periodic charges to the member. MSofA Dent-All Plan, Inc.-Texas will accept and cancel program memberships at any time during the membership period and we will cease collecting membership fees in a reasonable amount of time, but no later than 30 days after receiving a valid cancellation notice.

Limitations, Exclusions & Exceptions: This program is a discount membership program offered by MSofA Dent-All Plan, Inc.-Texas. MSofA Dent-All Plan, Inc.-Texas is NOT a licensed insurer, health maintenance organization, or other underwriter of health care services. No portion of any provider's fees will be reimbursed or otherwise paid by MSofA Dent-All Plan, Inc.-Texas. MSofA Dent-All Plan, Inc.-Texas is not licensed to provide and does not provide medical services or items to individuals. You will receive discounts for medical services at certain health care providers who have contracted with the plan. You are obligated to pay for all health care services at the time of your appointment. Savings are based upon the provider's usual and customary fees. Actual savings will vary depending upon location and specific services or products purchased. Please verify such services with each individual provider. The discounts contained herein may not be used in conjunction with any other discount plan or program. All listed or quoted prices are current prices by participating providers and subject to change without notice. Any procedures performed by a non-participating provider are not discounted. From time to time, certain providers may offer products or services to the general public at prices lower than the discounted prices available through this program. In such event, members will be charged the lowest price. Discounts on professional services are not available where prohibited by law. This plan does not discount all procedures. Providers are subject to change without notice and services may vary in some states. It is the member's responsibility to verify that the provider is a participant in the plan. At any time MSofA Dent-All Plan, Inc.-Texas has the right to eliminate a Participating Professional from the respective network in which they are associated and may substitute Provider networks at its sole discretion. MSofA Dent-All Plan, Inc.-Texas International cannot guarantee the continued participation of any provider. If he or she leaves the plan, you will need to select another provider. Providers contracted by MSofA Dent-All Plan, Inc.-Texas are solely responsible for the professional advice and treatment rendered to members and MSofA Dent-All Plan, Inc.-Texas disclaims any liability with respect to such matters. Services and service providers may change or be discontinued at anytime without notice.