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Dental Club One
Dental Club One administers dental plans and in multiple States. Certain rules must
be followed in order to protect you, the Insured, and Dental Club One, the Administrator.
- All Requests for Changes in Coverage Must be in Writing. Changes received by the 15th of the month will be effective
on the first of the month following your request. Requests received later than the 15th of the month will be effective
on the first day of the following month.
- You are Enrolled in a Voluntary Program with "On-Going Open Enrollment." Generally, if Dental Club One raises the
monthly rates, it is in July or December. Dental Club One reserves the right to raise rates at any time. Before Dental Club One raises rates, Dental Club One will fulfill any necessary requirements to warrant a change. An annual payment
of premium does not guarantee your monthly rate. Dental Club One reserves the right to change companies at any time. If Dental Club One changes companies, Dental Club One will enroll the client
with the new company automatically. You may need to change Dental Providers.
- You may cancel your coverage at any time. All Requests to Cancel Must be in Writing. Terminations will be effective
on the first day of the month following the request for termination.
- For Disputes with Dental Offices regarding Appointments, Referrals, Specialty Care, Work in Progress, or other
related issues, contact Customer Service at CAREINGTON INTERNATIONAL CORP: 1 (800) 290-0523 (listed below).
- Send all Inquiries to Address, E-mail or Fax Numbers listed below.
Customer Service - Toll Free Numbers*
UNITED HEALTHCARE DENTAL: 1 (800) 951-6171
DENTAL HEALTH SERVICES: 1 (800) 248-8108
GOLDEN WEST DENTAL & VISION 1 (800) 995-4124
CAREINGTON INTERNATIONAL CORP: 1 (800) 290-0523
* If your Plan Organization is not listed, call us at: 1 (800) 951-6171
Federal Reserve Bank
TEPL, Inc. DBA M C ADMINISTRATORS (The Company) is licensed to transact Electronic (ACH) banking through the Federal Reserve
Bank of the United States.
If Paying Monthly, The Company Debits the Account you Authorize in the 1st week of each Month. A $1.00 fee is added. If your
account does not have sufficient funds, Dental Club One will debit again on the 3rd Friday of that month. A $5.00 service fee is
added. After three unsuccessful attempts to collect funds, the coverage will be terminated.
Report Suspected Errors Within 60 days of the transaction appearing on your billing account statement (issued by your credit card company or banking institution). If you believe an error has been made or
if you need more information about a transaction listed on your billing account statement (issued by your credit card company or banking institution), please contact our office immediately. You may leave
a message 24 hours a day, 7 days a week. Fax, mail, or email Dental Club One at the address or phone number listed below. We will
investigate your question at no cost to you. If our investigation shows Dental Club One in error, Dental Club One will refund the
amount in error or credit your dental account.
Except for errors made by Dental Club One, Dental Club One will not credit funds older than 60 days after transactions appear.
Dental Club One
1186 Santa Fe Drive . Encinitas, California 92024
(800) 951-6171 . FAX (760) 634-1799
Email: info@dentalclubone.com
For PLATINUM GOLDEN WEST MANAGED CARE members only:
I AGREE:
To the best of my knowledge and belief, all information on this form is correct and true. I understand that this application and any information Golden West Dental & Vision obtains prior to the effective date of coverage is the basis on which coverage may be issued under the plan. I further authorize my employer to deduct any contribution required from my earnings to apply toward the cost of this plan. I certify that I am working at the employer’s place of business in permanent employment.
I AM APPLYING FOR HMO COVERAGE: I understand that, if I have applied for HMO coverage, that I am responsible for paying for services rendered that are not authorized by my selected HMO provider.
I AUTHORIZE: My dental professional, any hospital, clinic, any insurer or employer to give Golden West Dental & Vision information about me. Such information will pertain to my employment, other insurance coverage, or care, advice, treatment or supplies for any physical or medical condition.
ARBITRATION AGREEMENT:
If your coverage is under a private employer plan governed by ERISA (Employment Retirement Income Security At of 1974), certain disputes may not be subject to the following arbitration provisions:
I understand that any and all disputes between myself (and/or any enrolled dependent) and Golden West Dental & Vision, must be resolved by binding arbitration, if the amount in dispute exceeds the jurisdictional limit of the Small Claims Court, and not by lawsuit or resort to court process, except as California law provides for judicial review of arbitration proceedings. Under this coverage both the member/ dependent and Golden West Dental & Vision are giving up the right to have any dispute decided in a court of law before a jury. Golden West and the member and dependents also agree to give up any right to pursue on a class basis any claim or controversy against the other. For more information regarding binding arbitration, please refer to your Evidence of Coverage/Certificate.
If I am enrolled in an employer-sponsored benefit plan that is subject to ERISA (Employee Retirement Security Act of 1974, 29 U.S.C. section 1001, et seq.) I understand that any dispute involving an adverse benefit determination for a health claim may not be subject to mandatory binding arbitration. However, I further understand that any dispute I may have with respect to an adverse benefit determination for a health claim may be submitted to voluntary binding arbitration after the ERISA claim appeal process is completed.
I attest by signing below that I have reviewed the information provided on this application and to the best of my knowledge and belief, it is true and accurate with no omissions or misstatements.
For GOLD members only:
Disclosures:
1. THIS PLAN IS NOT INSURANCE.
2. The plan provides discounts at certain health care providers for medical services.
3. The plan does not make payments directly to the providers of medical services.
4. Plan members are obligated to pay for all health care services but will receive a discount from thosehealth care providers who have contracted with the discount medical plan organization.
5. Discount Medical Plan Organization and administrator:
CAREINGTON International Corporation, 7400
Gaylord Parkway, Frisco, TX 75034; phone 800-441-0380.
Note to Utah residents: This contract is not protected by the Utah Life and Health Guaranty Association. The program and its administrators have no liability for providing or guaranteeing service by providers or the quality of service rendered by providers. *This program is not available in Vermont and Montana.
This program is not insurance. It is a discount membership program offered by CAREINGTON. CAREINGTON 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 CAREINGTON. CAREINGTON is not licensed to provide and does not provide medical services or
items to individuals.
Savings are based upon the provider's normal fees. Actual savings will vary depending upon location and specific services
or products purchased. Please verify such discounts 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. Any procedure delivered which is not listed on the Schedule of Services may cause additional cost to
be incurred by the member. The dollar amount specified adjacent to each procedure may not be the only cost incurred for a given treatment
because the treatment may require more than one procedure. Specialist care may not be available in all areas. In cases in which you are
referred to a participating dental specialist, you will generally receive 20% off their normal fees. Some providers may
charge for missed or broken appointments if no prior notice is given.
Providers are subject to change without notice and discounts 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 CAREINGTON has the right to eliminate a Participating Professional from the
respective network in which they are associated. CAREINGTON 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 CAREINGTON are solely responsible for the professional advice and treatment rendered to members and PacifiCare
disclaims any liability with respect to such matters. Discounts and program providers may change or be discontinued at anytime with notice as required by law.
Work in progress, after enrollment on the plan, must be completed by the provider who started the work.
Should the initial provider choose to terminate the contract with Careington while members are in the course of receiving treatment, the member can choose from a list of other qualified providers to replace the existing provider.
You have 45 days from the time of enrollment to use the plan risk-free. If for some reason within 45 days you are dissatisfied with the
plan and wish to cancel, please send a cancellation letter with your name and member number to Member Services, Dental Club One at 1186
Santa Fe Dr., Encinitas, California 92024.
By enrolling for a plan online, you are authorizing Dental Club One to bill your credit card or checking account for the plan you have
selected. This charge shall remain in force until you notify Dental Club One in writing of its cancellation. By enrolling online, 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, and your credit card or bank account will be automatically charged or drafted for the appropriate amount.
The program and its administrators have no liability for providing or guaranteeing service or the quality of service rendered.
Disclosures:
1. THIS PLAN IS NOT INSURANCE.
2. The plan provides discounts at certain health care providers for medical services.
3. The plan does not make payments directly to the providers of medical services.
4. Plan members are obligated to pay for all health care services but will receive a discount from thosehealth care providers who have contracted with the discount medical plan organization.
5. Discount Medical Plan Organization and administrator:
CAREINGTON International Corporation, 7400
Gaylord Parkway, Frisco, TX 75034; phone 800-441-0380.
Note to Utah residents: This contract is not protected by the Utah Life and Health Guaranty Association. The program and its administrators have no liability for providing or guaranteeing service by providers or the quality of service rendered by providers. *This program is not available in Vermont and Montana.
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