Sapphire Membership Application
Terms & Conditions
SEVEN STAR DENTAL shall honor the terms & conditions set forth within the Sapphire Membership Program, including but not limited to set premiums, benefits, eligibility and coverage. (a) 100% savings on Comprehensive Examination (2 per year), Full Series X-Rays (1 per year), Adult/Child Prophylaxis (2 per year), and Topical Fluoride (1 per year). (b) 25% savings on all other dent al services, including Scaling/Root Planning (Deep Cleanings), Additional Cleanings (if more than 2 are required annually for treatment), and Orthodontics. The 25% savings excludes Botox© and Juvéderm© treatments. (c) 10% savings on Botox© and Juvéderm© tr eatments. THE SIGNER OF THIS AGREEMENT shall agree to have funds automatically deducted in order render membership payments at the time a payment is due, which will be considered a prepayment for the upcoming time period (month or year, depending on the subscription): (a) $29 per month for a single Sapphire Membership (b) $19 per month for an a dditional immediate family member (spouse or dependent child) (c) $9 per month for an additional dependent child age 12 and under. The Sapphire Membership Program is valid from the date of sign-up and initial payment, depending on the subscription terms, with payment and coverage auto-renewing monthly/annually indefinitely until termination is requested. You will not receive a membership card; your plan’s effective date will be on file with our office. Monthly or annual premium must be paid in full prior to receiving benefits. Co-payments must be paid at time of service or full procedure fee will be applied. Any services performed during a lapse in coverage will be subject to the full charge of the services. A lapse is defined as a non-payment greater than 31 days of the last payment if monthly, or 366 days if annually. There will be a $35 reinstatement fee if your plan lapses. Membership cannot be used in conjunction with another dental plan, and is non-refundable. Participant may cancel Membership at any time with written notice. No refunds of premiums will be issued at any time if participant decides not to utilize dental plan. Seven Star Dental reserves the right to change the terms and/or conditions of the Sapphire Membership Program. EXCLUSIONS & LIMITATIONS. The Seven Star Dental Sapphire Membership program is not a dental insurance plan. It cannot be used: (a) In conjunction with another dental plan. (b) For serv ices for injuries covered under workman’s compensation. (c) For treatment which, in the opinion of the treating dentist, lies outside the realm of their capability. (d) For referrals to other dentists or specialist. (e) For hospitalization or hospital charges of any kind. (f) For costs of dental care which is covered under automobile medical. (g) In combination with any other offers or special discounts.