(509) 497-7777 Mon-Thurs: 8am-5pm | Fri: 8am-3pm

DIRECT DENTAL SERVICES RETAINER AGREEMENT

 

This Direct Dental Services Retainer Agreement (the “Agreement”) is entered into and effective as of the date of enrollment (the “Effective Date”) between you the patient (“Patient” or “You”) and Mid-Columbia Dental (the “Practice”).

1. We Care Savings Plan. By entering into this Agreement, the Practice agrees to make certain dental services available to You as more fully described below (the “WeCare Savings Plan” or “WeCare”). By voluntarily entering into this Agreement, remitting the required fees, and otherwise complying with the terms contained herein, the Patient may participate in We Care. We Care includes the Patient’s ability to obtain dental services as follows during one 12-month Term (as defined below):

a. 2 cleanings at no cost;
b. 1 full set of x-rays at no cost;
c. 2 comprehensive exams at no cost;
d. 1 free emergency exam at no cost;
e. 35% off all crowns;
f. 25% off implants;
g. 10% off all other procedures offered by the Practice.

2. DISCLAIMER. The WeCare Savings Plan IS NOT INSURANCE. WeCare does not provide comprehensive health insurance coverage. WeCare provides only the limited, routine, dental services specifically described in this Agreement.

3. Term and Renewal. Your We Care Savings Plan will begin on the Effective Date and will continue for a period of one (1) year. Your WeCare Savings Plan will automatically renew each year on the anniversary of the Effective Date unless cancelled by either party upon written notice. Each one-year period after the initial Term of this Agreement will be considered a “Renewal Term.”

4. Services and Costs. The dental services provided to You under WeCare are provided only during the Term, or Renewal Term of this Agreement and are subject to reasonable scheduling requests. You are solely responsible for ensuring your WeCare services are scheduled during the time permitted under this Agreement. Services under WeCare may not be carried over beyond the time allowed.

5. Payments.
a. Enrollment in We Care is thirty dollars ($30.00) per month for the first member. Spouses of a member may be enrolled for an additional $27.50 per month, and children under the age of 18 of a member may be enrolled for an additional $25.00 per month.

b. Payments are due monthly under this Agreement but may be eligible for refunds under the termination provisions below.

c. All payments required under this Agreement must be made by automatic payment by debit card, or credit card. You agree to provide Practice with a valid method of payment which will be updated if necessary to ensure payments are timely made to Practice. Failure to pay any required payment will result in termination of this Agreement thirty (30) days after the due date of the missed payment. Practice will not provide any services to Patient while
any payment from Patient remains unpaid.

6. Termination. Either party may cancel this Agreement at any time by providing written notice to the other party. Upon termination, the Practice will refund to You the unused portion of your fees on a per diem basis, less any unpaid fees for services rendered prior to
termination.

7. Amendments and Waivers. This Agreement may only be revoked, altered, amended, or modified by written agreement of both parties hereto. No waiver or any provisions of this Agreement shall be valid unless in writing and signed by the party against whom such waiver is sought. One or more waivers of any covenant or condition of this Agreement by any of the parties shall not be construed as a waiver of any subsequent breach of the same provision or of any other covenants or conditions.

8. Invalid Provisions. The invalidity or unenforceability of any particular provision of this Agreement shall be construed in all respects as if such invalid or unenforceable provisions were omitted.

9. Entire Agreement. This Agreement contains the entire understanding of the parties with respect to the subject matter outlined in this Agreement. The undersigned agrees to the terms and conditions of this Agreement and acknowledges there are no promises or representations except as specifically listed in this Agreement.

10. Governing Law. This Agreement shall be governed by and construed in accordance with the laws of the State of Washington.

11. DISCLOSURES. THIS AGREEMENT CONTAINS ALL THE TERMS OF THE ARRANGEMENT BETWEEN YOU AND THE PRACTICE. ALL OF PATIENT’S FINANCIAL RIGHTS AND RESPONSIBILITIES TO THE PRACTICE ARE CONTAINED IN THIS AGREEMENT. THE PRACTICE RECOMMENDS AND ENCOURAGES THE PATIENT TO MAINTAIN INSURANCE FOR ALL MEDICAL NEEDS NOT PROVIDED BY THE PRACTICE UNDER WE CARE. THE PRACTICE WILL NOT BILL INSURANCE CARRIERS FOR SERVICES COVERED UNDER THIS AGREEMENT. THE OFFICE OF THE INSURANCE COMMISSIONER, WASHINGTON STATE, MAY BE CONTACTED AT 800-562-6900, 360-725-7100, OR P.O. BOX 40255, OLYMPIA, WA 98504-0255, 302 SID SNYDER AVE., SW, SUITE 200, OLYMPIA, WA 98504.

12. Contact Person for Practice. All Patient complaints, concerns, or terminations of this Agreement, must be addressed to the following:
Mid-Columbia Dental
ATTN: Billing
2620 S. Williams Pl. Ste. 120
Kennewick, WA 99338

Close Menu