Lake Merced Dental Membership Plan

• Membership is for one year beginning on the enrollment date
• Each additional family membership must be paid at the time of the initial membership or at renewal time
• Membership dues are payable in full upon enrollment
• Cash, check or credit card payments accepted
• Membership will automatically renew on the anniversary date unless written request to cancel is received prior to renewal date
• Member gives permission for Lake Merced Dentistry to process their credit card on the annual renewal date unless written request to cancel is received prior to renewal date
• Annual membership fees may be adjusted annually
• Member will be informed of any increase in annual membership fee prior to renewal
• Members are responsible for notifying Lake Merced Dentistry of any address or contact changes
• Missed appointment fees are ineligible for the membership discount
• Membership may be terminated at will by written notice from the patient to Lake Merced Dentistry
• Lake Merced Dentistry may terminate the membership by written notice to the patient when terminating the doctor patient relationship or discontinuing the membership program
• Membership benefits are not transferable, have no cash value and may not be redeemed for cash
• This is not an insurance plan and is not subject to regulation by the state department of insurance
• Plan membership cannot be combined with current dental insurance plans
• No insurance claim will be filed for Members under this plan
• The plan is for individual use only. It is not a group benefit plan
• Payments for additional dental services are the member’s responsibility
• Additional dental service fee will be based upon the fee at the date of service
• Payment is due on the date of service to qualify for the discounts detailed above
• Membership must be current to receive the discount
• Fees for dental services may change at any time
• Lake Merced Dentistry retains the right to interpret the program stipulations
• It is the member’s responsibility to schedule and keep all appointments offered as part of the Dental Membership Program
• Please notify our office at least 48 hours in advance if you must change a scheduled appointment
• No deductibles, no pre-authorizations, no yearly maximums, no waiting period
• No exclusions for elective care

Disclaimer: This agreement does not provide health insurance coverage, including the minimal essential coverage required by applicable federal law. It provides only the services described herein. It is recommended that health care insurance be obtained to cover dental services not provided for under this in-office membership care agreement.