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Member Registration Form

Use the form below to enroll in the Dental Care Advantage program administered by American Dental Professional Services. If you have any questions about completing your application, please contact us at 855-322-4322.

We will process your Dental Care Advantage application upon receipt. You will receive your identification card in the mail.

Plan Details *

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Mailing Address *

I would like to be effective the 1st of

Dependents

Agreement *

Form-Member Registration

Terms and Conditions

The Dental Care Advantage program provides members access to a network of participating healthcare providers that have agreed to make certain health care services available to members at a pre-negotiated discount. The healthcare services available include discounted dental, vision, chiropractic, and hearing, Prescription drug discounts are also available with the Dental Care Advantage non-senior program. The programs do not discount all procedures. The programs do not provide discounts on other medical or hospital services.

The discounted services are offered by independent providers who are not employees or agents of American Dental Professional Services (ADPS). ADPS does not guarantee the continued participation of any provider in a program and provider fees are subject to change without direct notice. The discount programs may not be used in conjunction with any other plan or program. Please verify your payment responsibility prior to receiving services.

Enrollment Applications will be made effective the 1st of the month received unless specifically requested by the member to be effective the 1st of a month earlier or later. Annual payers will be effective for 12 months after their initial effective date. An invoice for renewal will be sent to annual payers approximately 45 days before the end of this period. If a renewal payment is not received by the annual termination date, the membership will be cancelled. Monthly payers will be effective as long as the member continues to pay via credit card transaction that is automatically processed by ADPS on the 3rd of each month for that month. Monthly payers must notify ADPS by phone or in writing when they wish to cancel their membership. Membership will be terminated effective the last day of the month that ADPS receives notification.

Membership can be cancelled at any time. Requests to cancel can be made via phone, fax, e-mail or regular mail. If the member cancels the membership within the first thirty (30) days after the effective date of enrollment in the plan the member shall receive a reimbursement of all periodic charges. If the member cancels the membership after a period of thirty (30) days, the reimbursement of membership fees will be prorated. If refund is not received within 30 days interest will be paid. ADPS reserves the right to terminate a program member from any of the discount programs with a ninety (90) day prior notice. In this event program fees will be prorated and refunded in the same manner as noted above.

To find a participating provider for dental, vision, chiropractic or pharmacy services, visit our web site at www.dentalcareadvantage.com or contact our Customer Service Department at 1-855-322-4322. For Hearing Services, please call EPIC Hearing at 1-866-956-5400 and tell them you are with the Dental Care Advantage Program. When scheduling an appointment with a provider, be sure to reference the correct network and logo listed on your ID card. Present your ID card each time you receive services. Each family member can choose their own contracted health care provider. The program allows conditions existing prior to enrollment to be discounted if the treatment needed is listed in the fee schedule. You must continue to be a member of the program throughout your entire treatment, to be eligible for continued discounted services.

Disclosures

This program is NOT a health insurance policy and the program does not make payments directly to the providers of health services. This program provides discounts at certain health care providers for medical services. The program member is obligated to pay the provider for all the health care services that the member will receive, but the member will receive a pre-negotiated discount from the providers listed in the network, in accordance with the specific pre-negotiated discounted fee schedule. This program does not guarantee the quality of the services or procedures offered by the providers. Discounts vary by provider. The Discount Medical Plan Organization that operates this program is American Dental Professional Services, LLC located at 9054 N. Deerbrook Trail, Milwaukee, WI 53223. (Not available in the states of Alaska, California, Connecticut, Illinois, Kansas, Montana, Nebraska, Nevada, New Jersey, Rhode Island, South Dakota, Utah, Vermont, Washington and West Virginia).

American Dental Professional Services, LLC     9054 North Deerbrook Trail    Milwaukee, WI 53223

Phone: 1-855-322-4322       1-414-203-2590      Fax: 1-877-545-4549   www.dentalcareadvantage.com

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