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Terms and Conditions
CRESTED OAK DENTISTRY
MEDICAL RETAINER AGREEMENT

Background

Crested Oak Dentistry is a Direct Primary Care dental practice (“DPC”), which delivers dental services at 2532 Patterson Rd. STE 1 Grand Junction, CO 81505 AND 102 Main St. STE 100 Delta, CO 81416. In exchange for certain fees, the practice, agrees to provide you with the services described in Appendix B on terms and conditions contained in this agreement (“Agreement”).

Definitions

1. Patient. In this Agreement, “Patient” means the persons for whom the Dentist shall provide care, and who have signed this agreement or are listed on the document attached as
Appendix B, which is a part of this agreement.

2. Services. In this Agreement, “Services”, means the collection of services, offered to you by Crested Oak Dentistry in this Agreement. These Services are listed in Appendix A (1), which is attached and a part of this Agreement.

Agreement

3. NOTICE: THIS MEDICAL RETAINER AGREEMENT DOES NOT CONSTITUTE INSURANCE, IS NOT A MEDICAL PLAN THAT PROVIDES HEALTH INSURANCE COVERAGE FOR PURPOSES OF THE FEDERAL PATIENT PROTECTION AND AFFORDABLE CARE ACT AND COVERS ONLY LIMITED, ROUTINE HEALTH CARE SERVICES AS DESIGNATED IN THIS
AGREEMENT.

4. Term. This Agreement will last for one (1) year, starting on the date this agreement is signed.
There is a one time, 30-day processing period before coverage begins. During this 30-day period the contract can be cancelled by either party for any reason with a full refund. After this 30 day period, no refunds will be given for any reason.

5. Renewal. The Agreement will automatically renew each year on the anniversary date of the agreement, unless either party cancels the Agreement by giving thirty (30) days prior written cancellation notice.

6. Payments – Amount and Methods. In exchange for the Services (see Appendix A(1), You agree to pay Crested Oak Dentistry, a monthly or annual fee in the amount that appears in Appendix C, which is attached and is part of this Agreement.

a) This monthly or annual fee is payable when you sign the Agreement, and is due on the first (or on the day you signed up) business day of each month or each year thereafter.
b) The Parties agree that the required method of monthly or annual payment shall be by automatic payment, through a debit, Bank ACH or credit card.

c) No refunds or premiums will be issued at any time if the participant decides not to utilize the dental plan.

8. This Is Not Health Insurance. Your signature acknowledges your understanding that this Agreement is not an insurance plan or a substitute for health insurance. You understand that this Agreement does not replace any existing or future health insurance or health plan coverage that you may carry.
The Agreement does not cover services for injuries covered under Workman’s Compensation. The Agreement does not include hospital services, dental specialists’ services, or any services not personally provided by Crested Oak Dentistry or its employees. You acknowledge that the practice has advised you to obtain or keep in full force, medical health insurance that will cover you for healthcare not personally delivered by the practice, and for hospitalizations and catastrophic events.
The Agreement does not cover treatment, which, in the sole opinion of the treating dentist, lies outside the realm of their capability.

9. Communications. The Patient acknowledges that although Crested Oak Dentistry shall comply with HIPAA privacy requirements, communications with the dentist using e-mail, facsimile, video chat, cell phone, texting, and other forms of electronic communication can never be absolutely guaranteed to be secure or confidential methods of communications. As such, Patient expressly waives the Dentist’s obligation to guarantee confidentiality with respect to the above means of communication. Patient further acknowledges that all such communications may become a part of the medical record.

By providing an e-mail address on the attached Appendix B and/or during online enrollment, the patient authorizes Crested Oak Dentistry, and its owners, employees and representatives to communicate with him/her by e-mail regarding the patient’s “protected health information” (PHI).1 The Patient further acknowledges that:
(a) E-mail is not necessarily a secure medium for sending or receiving PHI and, there is always a possibility that a third party may gain access;

(c) At the discretion of the dentist, e-mail communications may be made a part of Patient’s permanent medical record; and,

(d) In an emergency, or a situation that you could reasonably expect to develop into an emergency, you understand and agree to call 911 or the nearest emergency room, and follow the directions of emergency personnel.

10. Dentist Absence. From time to time, due to vacations, illness, or personal emergency, the dentist may be temporarily unavailable to provide the services referred to above in this paragraph one. In the event of the dentist’s absence during usual clinic hours, Patients will be given the name and telephone number of an appropriate provider for the Patient to contact. Any treatment rendered by a non-clinic substitute provider is not covered under this contract, but may be submitted to patient’s health plan.

11. Change of Law. If there is a change of any relevant law, regulation or rule, federal, state or local, which affects the terms of this Agreement, the parties agree to amend this Agreement to comply with the law.

12. Severability. Member acknowledges that participation in this plan constitutes agreement of the contract for the period of one year and payment of the entire contract fee (even if paid on a monthly basis). It is not refundable for any reason. If the contract is in default for non-payment, the member agrees to pay for reasonable collection, attorney and court fees for settlement of the balance.
If any part of this Agreement is considered legally invalid or unenforceable by a court of competent jurisdiction, that part will be amended to the extent necessary to be enforceable, and the remainder of the contract will stay in force as originally written.

13. Reimbursement for Services Rendered. If this Agreement is held to be invalid for any reason, and the practice is required to refund fees paid by you, you agree to pay the practice an amount equal to the fair market value of the medical services you received during the time period for which the refunded fees were paid.

14. Amendment. No amendment of this Agreement shall be binding on a party unless it is in writing and signed by all the parties. Except for amendments made in compliance with Section 12 above.

15. Assignment. This Agreement, and any rights you may have under it, may not be assigned or transferred by you.

16. Legal Significance. You acknowledge that this Agreement is a legal document and gives the parties certain rights and responsibilities. You also acknowledge that you have had a reasonable time to seek legal advice regarding the Agreement and have either chosen not to do so or have done so and are satisfied with the terms and conditions of the Agreement.

17. Miscellaneous. This Agreement shall be construed without regard to any rules requiring that it be construed against the party who drafted the Agreement. The captions in this Agreement are only for the sake of convenience and have no legal meaning.

18. Entire Agreement. This Agreement contains the entire agreement between the parties and replaces any earlier understandings and agreements whether they are written or oral.

19. No Waiver. In order to allow for the flexibility of certain terms of the Agreement, each party agrees that they may choose to delay or not to enforce the other party’s requirement or duty under this agreement (for example notice periods, payment terms, etc.). Doing so will not constitute a waiver of that duty or responsibility. The party will have the right to enforce such terms again at any time.

20. Jurisdiction. This Agreement shall be governed and construed under the laws of the State of Colorado. All disputes arising out of this Agreement shall be settled in the court of proper venue and jurisdiction for Mesa County OR Delta County, Colorado.

21. Service. All written notices are deemed served if sent to the address of the party written above or appearing in Appendix B by first class U.S. mail.




APPENDIX A SERVICES

Dental Services. Dental & medical services under this agreement are those medical services that the Dentist is permitted to perform under the laws of the State of Colorado, are consistent with dentist’s training and experience, are usual and customary for a dental physician to provide, and include the following:

List of Benefits:

BREEZE PLAN:
2 periodic exams per year, 2 cleanings per year (4x per year if periodontal option is selected-+$20/mo.), 4 Bitewing x-rays per year, Full mouth x-rays or panoramic (1 every 3 years), Unlimited emergency/limited exams, Invisalign- $500 off (must remain on plan for treatment duration). Lab based restorations- 20% off. All other treatment-20% off.

MEMBERS PLUS PLAN:
2 periodic exams per year, 2 cleanings per year (4x per year if periodontal option is selected-+$20/mo.), 4 Bitewing x-rays per year, Full mouth x-rays or panoramic (1 every 3 years), Unlimited emergency/limited exams, Invisalign- $750 off (must remain on plan for treatment duration). Lab based restorations- 20% off. All other treatment-40% off.



a. b. E-Mail Access. Patient shall be given the practice’s e-mail address to which non-urgent communications can be addressed. Such communications shall be dealt with by the dentist or staff member of Crested Oak Dentistry in a timely manner. Patient understands and agrees that email and the internet should never be used to access medical care in the event of an emergency, or any situation that Patient could reasonably expect may develop into an emergency.

Patient agrees that in such situations, when a patient cannot speak to the dentist immediately in person or by telephone, that patient shall call 911 or the nearest emergency medical assistance provider, and follow the directions of emergency medical personnel.

c. Specialists: Patient understands that fees paid under this Agreement do not include and do not cover specialist fees or fees due to any medical professional other than Crested Oak Dentistry staff.



















APPENDIX B

PATIENT ENROLLMENT – MEDICAL AGREEMENT FORM

Annual and monthly fees as set out in Appendix C shall apply to the following Patient(s), who by signing below agree to the terms and conditions of the Crested Oak Dentistry Medical Agreement Form.

*All patients must have a credit or debit card on file to cover the cost of membership & any incidentals not covered under the Agreement.

I certify that I have read, understand, and agree to the terms set forth in this Medical Agreement Form. I further certify that I have received a copy of this form.




APPENDIX C

MEMBERSHIP PRICE

BREEZE PLAN:
Adult (Age 19+) $35/month + $50 administrative fee (*fee waived if paid at annual rate)
Child (Age 1-18) $30/month + $50 administrative fee (*fee waived if paid at annual rate)

MEMBERS PLUS PLAN: *REQUIRES AT LEAST 1 ADULT ON PLAN
Adult (Age 19+) $70/month +$50 administrative fee (*fee waived if paid at annual rate)
Child (Age 1-18) $19/month +$50 administrative fee (*fee waived if paid at annual rate)
 
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