There is a non-refundable enrollment fee of $95.00 per family.
Lavaan Dental Spa Prepaid/Discount Dental Services Plan
Terms & Conditions
Enrollment and Payment
By completing and signing this Enrollment Form, and paying the annual enrollment fee, the patient (You) have agreed to the terms and conditions of the Plan as stated in this form. You are currently enrolled for one year, 365 days, from the effective date of enrollment as stated on this form by an authorized Plan representative (the "Enrollment Term”).
If You have paid the initial enrollment fee by credit card, then the Plan will automatically renew at the end of each Enrollment Term on an annual basis. Your credit card will be automatically charged the annual enrollment fee, unless You cancel your enrollment in the Plan as provided below in these Terms and Conditions. If You have paid the initial enrollment fee by check, then your enrollment will end at the end of the Enrollment Term, unless You renew your enrollment and pay the annual enrollment fee.
This Plan is a prepaid and discount membership program for dental services which is being offered by Lavaan Dental Spa. Certain dentists and dental practices have contracted with the Plan to be participating providers to provide certain specified dental services (Covered Services) for the discounted fees which are listed in the attached Plan Fee Schedule. These participating providers have also agreed to charge You the discounted fees listed in this Fee Schedule for treating You for any complications which may occur in their providing of the Covered Services for You.
At the time of your appointment You are obligated to pay the participating dentist directly for all the non-covered and Covered Services he/she provides for You; however, for Covered Services, and complications with Covered Services, You will be charged the discounted fees listed in the Plan's Fee Schedule.
In terms of the prepaid portion of the Plan, included with the annual enrollment fee are four teeth cleanings per Enrollment Term (adult or children) to be provided by Lavaan Dental Spa. These are the only dental services which Lavaan Dental Spa will be directly providing under the Plan. All other Covered Services will be provided by the participating providers.
Limitations, Exclusions & Exceptions
Not all dental services are Covered Services under the Plan, only those listed in the Fee Schedule are Covered Services being provided by participating providers for the discounted fees listed in the Fee Schedule.
The Plan reserves the right to change, add-to, or subtract-from the list of Covered Services, and the Fee Schedule for them, at any time, and from time-to-time, during the Enrollment Term upon thirty(30)Days written notice to You.
If you require any dental services which are not Covered Services, then, under the Plan, the participating providers have agreed to charge You the usual and customary rates (“UCR”) which they charge their other patients for providing these non-covered services. (You must consult with the participating provider for his/her UCR fee schedule for these non-covered service fees.)
Not all dentists in New York City have agreed to be participating providers in the Plan. Before having any dental services performed, it is Your responsibility to check with the individual dentist or practice to determine whether he/it is a participating provider in the Plan.
Attached to this Enrollment Form is a list of the Plan’s current participating providers. This list will be updated on the Lavaan Dental Spa website from time-to-time as additional dentists contract to become participating providers or terminate their participation in the Plan. It is your responsibility, prior to receiving any treatment\care, to determine whether the dentist is a participating provider at that time. You can also e-mail a request to Lavaan Dental Spa, and a current list of participating providers will be sent to You electronically.
Not all participating dentist or dental practices will be providing all the Covered Services listed in the attached Plan Fee Schedule. It is your responsibility to determine, prior to receiving any treatment/care, those Covered Services which the participating dentist or practice is providing.
The Plan does not, and cannot, guarantee that any particular dentist or dental practice will become, or will continue, as a participating provider for any period of time. Under the Provider Participation Agreement any participating dentist or practice may terminate its participation in the Plan upon 30 days, and in some situations only 10 days, notice to the Plan. In addition, within these same notice periods the Plan has the right to terminate the participation of any dentist or practice.
If the participating dentist with whom you are treating terminates his/her participation in the Plan, then You will have to select another participating dentist with whom to begin treating in order to continue being charged the discounted fees listed in the Plan's Fee Schedule for Covered Services and complications with Covered Services
This Plan is not insurance and is not intended to replace dental insurance. It is not a Qualified Health Plan under the Affordable Care Act. The Plan, and Lavaan Dental Spa, are not licensed insurers, health maintenance organizations, or other underwriters of health care (dental) services. The Plan does not make any payments directly to providers of dental services. The Plan does not pay any portion of any fees You may be charged for any dental services by a dentist who is participating in the Plan.
Participating dentists are solely responsible for billing and collecting from You the fees which they have charged for providing both non-covered and Covered Services. The Plan has no responsibility, nor any liability, for billing or collecting these fees. Any disputes over the fees charged by participating dentist must be addressed by You with them.
Participating providers are solely responsible for the professional advice, treatment and care, and the overall quality, of the dental services they provide for You. The Plan, and Lavaan Dental Spa, are making no representations, warrantees, nor any guarantees regarding any aspects of the dental services, or the quality of them, being provided by participating dentists. The Plan, and Lavaan Dental Spa, have no obligations, responsibilities, nor any liabilities to You, with regard to any of these matters, and You must address all of them solely with the participating dentist who treated You.
You have the right to cancel your enrollment in the Plan at any time during the initial thirty (30) days of any Enrollment Term, and You will receive a full refund of your enrollment fee for that Enrollment Term. (If during this thirty (30) day period You have had any teeth cleanings performed by Lavaan Dental Spa, its standard fee for the cleaning(s) will be deducted from this refund.)
You can cancel your enrollment by email using the Lavaan Dental Spa website or by regular mail. Cancellations over the phone cannot be accepted. If You cancel your enrollment after this initial thirty (30) day period, then your cancellation will be effective at the end of the Enrollment Term.
Lavaan Dental Spa has the right to terminate your enrollment in the Plan at any time for any reason, including for the non-payment of your enrollment fee. If Lavaan Dental Spa terminates your enrollment for any reason, other than the non-payment of your enrollment fee, then Lavaan Dental Spa will give You a pro-rated refund of your enrollment fee for the Enrollment Term. (For example; if Lavaan Dental Spa terminates your enrollment for any reason, other than non-payment of the enrollment fee, at the end of six months of any Enrollment Term, You will receive a refund of half your enrollment fee for that Enrollment Term (which is for a year, 365 days).
If You have any complaints about how Lavaan Dental Spa is administering/operating the Plan, or about the pre-paid dental services which Lavaan Dental Spa is providing under the Plan, You can submit the complaint by email using the Lavaan Dental Spa website or by regular mail. Complaints over the phone cannot be accepted. The Plan will make every reasonable effort to respond to your complaint, either by email or regular mail, with three (3) business days after it is received.
If your complaint is about the dental services provided by a participating dentist or dental practice, the fees you were charged, or any other dissatisfaction with a participating dentist or practice, all these types of complaints must be addressed directly with the dentist or practice.
I acknowledge that I have read this form; that I understand it; that any questions I may have had about it have been answered to my complete satisfaction; and that I have voluntarily signed this form.