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Terms and Conditions

Croft In-House Savings Plan
MEDICAL RETAINER AGREEMENT


Background

G. Curtis Croft D.D.S. Inc. is a direct primary care dental practice (DPC), that delivers dental services at 118 Natoma Street, Folsom, CA 95630. In exchange for certain fees, the practice agrees to provide you with the services described and contained in this Agreement.

Definitions

1. Patient. In this Agreement “patient(s)” means the person(s) for whom the dentist shall provide care, who have signed this Agreement or are listed on “Appendix B”, that is attached and part of this Agreement.

2. Services. In this Agreement “services” means the collection of services offered to you, the patient(s), by G. Curtis Croft D.D.S. Inc. These services are listed in Appendix A(1) that is attached and part of this Agreement.

3. Preventative. In this Agreement “preventative” means services such as cleanings, exams, x-rays and fluoride. These services are paid through your, the patient(s), yearly or monthly Agreement.

4. Treatment. In this Agreement “treatment” means services such as, but not limited to, crowns, fillings, implants, bridges etc. These services require payment at time of service. In some cases the doctor may find that you, the patient(s), need a specialist and will refer you to a specialist for certain treatment.

Agreement

5. NOTICE: THIS MEDICAL RETAINER AGREEMENT DOES NOT CONSTITUTE INSURANCE, IS NOT A MEDICAL PLAN THAT PROVIDES HEALTH INSURANCE COVERAGE FOR PURPOSES OF THE FEDERAL PATIENT PROTECTION AND AFFORDABLE CARE ACT AND COVERS ONLY LIMITED, ROUTINE HEALTH CARE SERVICES AS DESIGNATED IN THIS
AGREEMENT. THIS IS A DENTAL DISCOUNT PLAN AND IS NOT DENTAL INSURANCE. IT CANNOT BE COMBINED WITH DENTAL INSURANCE. IF PATIENT BEGINS COVERAGE UNDER ANY DENTAL INSURANCE PLAN, HE/SHE IS NO LONGER ELIGIBLE TO PARTICIPATE IN THE IN-HOUSE SAVINGS PLAN. G. CURTIS CROFT D.D.S. INC. IS NOT A LICENSED INSURER, HEALTH MAINTENANCE ORGANIZATION, OR OTHER UNDERWRITER OF HEALTH SERVICES.



6. Term. This Agreement will last for one (1) year, for all patient(s) listed on Appendix A, starting on the date this Agreement is signed. Preventative benefits cannot be extended, do not roll over and must be completed within the one (1) year Agreement. This Agreement begins on the date signed, not the date of the first appointment. Cleanings and exams cannot be guaranteed if not scheduled prior to the last four (4) weeks of your, the patient(s), Agreement.

7. Renewal. This Agreement will automatically renew each year and is subject to change on the renewal date of the Agreement. Patient(s) will be given notice of any changes prior to auto-renewal. Either party may cancel this Agreement by giving thirty (30) days prior, written cancellation notice.

8. Termination. You always have the right to cancel this Agreement. Either party can end this Agreement at any time by giving the other party thirty (30) days prior written notice.

9. Payments and Refunds – Amount and Methods. In exchange for services (Appendix A [1]), the patient(s) agree to pay G. Curtis Croft D.D.S. Inc. a monthly or annual fee in the amount that appears in Appendix C that is attached and is part of this Agreement.

a) Monthly or yearly fees are due on the day this Agreement is signed and recurring monthly or yearly on the same day thereafter.

b) Parties agree that the required method of monthly or yearly payments for preventative care shall be by automatic payment through bank Automated Clearing House (ACH) or credit card.

c)The signee of this Agreement understands that all charges incurred by the patient(s) or its members linked in the Boomcloud software or listed on Appendix C are the financial responsibility of the signee.

d) This Agreement cannot be combined with any other offers. No other discounts are applicable.

e) When choosing to use third-party-financing, the discounted rate is 5% off instead of 10% or 15% off on additional cleanings, night guards or other treatment.

f) If this Agreement is cancelled by either party before the Agreement auto renewal date, G. Curtis Croft D.D.S. Inc. or its designee will review and settle your account as follows:

We will refund to you, the patient(s), the unused portion of your fees on a per diem basis; or
If the value of the services you received over the term of the Agreement exceeds the amount you paid in membership fees, you, the patient(s), shall reimburse G. Curtis Croft D.D.S. Inc in an amount equal to the difference between the value of the services received and the amount you paid in membership fees over the term of the Agreement. All parties agree that the value of services is equal to the practice’s usual and customary fee-for-service charges. A copy of these fees is available on request.

10. This Is Not Health Insurance. Your, the patient(s), signature on this Agreement acknowledges your understanding that this Agreement is not an insurance plan or a substitute for health insurance. You, the patient(s), understand that this Agreement does not replace any existing or future health insurance or health plan coverage that you may carry. This Agreement does not include hospital services, dental specialists’ services or any services not personally provided by G. Curtis Croft D.D.S. Inc. or its employees. You, the patient(s), acknowledge that the practice has advised you to obtain or keep in full force health insurance for healthcare not personally delivered by the practice.

11. Communications. You, the patient(s), acknowledge that although G. Curtis Croft D.D.S. Inc. shall comply with HIPAA privacy requirements, communications with the dentist using email, facsimile, video chat, cellphone, texting and other forms of electronic communication are not guaranteed to be secure or confidential methods of communications. As such, Patient(s) expressly waive the Dentist’s obligation to guarantee confidentiality with respect to the above means of communication. Patient(s) further acknowledges that all such communications may become a part of the medical record.

By providing an email address on the attached Appendix B and/or during online enrollment, the patient(s) authorizes G. Curtis Croft D.D.S. Inc. and its owners, employees and representatives to communicate with him/her by email regarding the patient(s) Protected Health Information (PHI). The patient(s) further acknowledges that:

(a) Email is not a guaranteed secure medium for sending or receiving PHI.

(b) G. Curtis Croft D.D.S. Inc. will make all reasonable efforts to keep email communications confidential and secure. Neither the practice nor the dentist can assure confidentiality of email communications.

(c) At the discretion of the dentist, email communications may be made a part of the patient(s) permanent medical record.

(d) You, the patient(s), understand and agree that email is not an appropriate means of communication in an emergency, for time-sensitive issues or for disclosing sensitive information. In an emergency, or a situation that could reasonably develop into an emergency, you, the patient(s), understand and agree to seek immediate emergency medical attention, call 911 or go to the nearest emergency room.

(e) Neither G. Curtis Croft D.D.S. Inc. nor the dentist will be liable for any loss, injury or expense arising from a delay in responding to patient(s) when that delay is caused by technical failure. Examples of technical failures: (i) failures caused by an internet service provider, (ii) power outages, (iii) failure of electronic messaging software or email provider (iv) failure of the practice’s computers or computer network or faulty telephone/cable data transmission, (iv) any interception of email communications by a third-party that is unauthorized by the practice or (v) patient(s) failure to comply with the guidelines for use of email described in this Agreement.

12. Dentist Absence. Occasionally the dentist may be temporarily unavailable to provide the services referred to above. In the event of the dentist’s absence during usual clinic hours, patient(s) will be given the name and telephone number of an alternate provider to contact. Any treatment rendered by a non-clinic substitute provider is not covered under this contract.

13. Change of Law. In the event of federal, state or local law or regulation change that affects terms of this Agreement, all parties agree to amend this Agreement to comply with the law.

14. Severability. If any part of this Agreement is considered legally invalid or unenforceable by a court of competent jurisdiction, that part will be amended to the extent necessary to be enforceable and the remainder of the contract will stay in force as originally written.

15. Reimbursement for Services Rendered. If for any reason and the practice is required to refund fees paid by you, the patient(s), you agree to pay the practice an amount equal to the fair-market-value of the medical services you, the patient(s) received during the time period for which the refunded fees were paid.

16. Amendment. No amendment of this Agreement shall be binding unless it is in writing and signed by all parties with the exception of Section 14 as stated.

17. Assignment. This Agreement, and any rights you, the patient(s), may have under it, may not be assigned or transferred. This plan is non-transferrable. Members cannot be substituted in for another member; all members must reside in the same household.

18. Legal Significance. You, the patient(s) acknowledge that this Agreement is a legal document and gives the parties certain rights and responsibilities. You, the patient(s) also acknowledge that you have had reasonable time to seek legal advice regarding this Agreement and have either chosen not to do so or have done so and are satisfied with the terms and conditions of this Agreement.

19. Miscellaneous. This Agreement shall be construed without regard to any rules requiring that it be construed against the party who drafted the Agreement.

20. Entire Agreement. This Agreement contains the entire Agreement between all parties and replaces any in-house plan, earlier payment arrangements, understandings and/or agreements whether they are written or oral.

21. No Waiver. In order to allow for the flexibility of certain terms of this Agreement, each party agrees that they may choose to delay or not to enforce the other party’s requirement or duty under this Agreement (ie: notice periods, payment terms, etc.). Doing so will not constitute a waiver of that duty or responsibility. The party will have the right to enforce such terms again at any time.

22. Jurisdiction. This Agreement shall be governed and construed under the laws of the State of California. All disputes arising out of this Agreement shall be settled in the court of proper venue and jurisdiction for Sacramento County, California.

23. Service. All written notices are deemed served if sent to the address of the party written above, or parties appearing in Appendix B, by first class U.S. mail.

24. Office Policies. All medical and clerical office policies required by G.Curtis Croft D.D.S. Inc. are not replaced with this Agreement.



APPENDIX A SERVICES

Dental Services. Dental and medical services under this Agreement are those medical services that the dentist is permitted to perform under the laws of the State of California, are consistent with the dentist’s training and experience, are usual and customary for a dental physician to provide and include the following:

List of Benefits:
Preventative (yearly):
Professional Cleanings or PMTs (2 per year)
Doctor Exams (1-2 per year as needed)
Oral Cancer Screening (1 per year)
Fluoride Treatment (2 per year)
All x-rays (as needed)
1 Emergency Exam (during regular business hours)
10% Off Additional Cleanings or PMTs*
Treatment:
15% Off Night Guards*
10% Off all Other Treatment*

*When choosing to use third party financing the discounted rate is 5% off instead of the 10% or 15% on additional cleanings or PMTs, night guards or treatment. Discounts do not apply to lab upgrades.

2. Non-Medical, Personalized Services. G. Curtis Croft D.D.S. Inc. shall also provide Patient(s) with the following non-medical services that are complementary to our members in the course of care:

a. After Hours Access. Patient(s) shall have telephone access to the practice’s answering service seven (7) days per week. Emergency exams after regular business hours will be charged our customary after hours emergency fee.

b. Email Access. Patient(s) shall be given the practice’s email address to which non-urgent communications can be addressed. Such communications shall be dealt with by the dentist or staff member of G. Curtis Croft D.D.S. Inc. in a timely manner. Patient(s) understands and agrees that email and the internet should never be used to access medical care in the event of an emergency or any situation that may develop into an emergency.

Patient(s) agree that in such situations, when a patient(s) cannot speak to the dentist immediately in person or by telephone, that patient(s) shall call 911 or the nearest emergency medical assistance provider.

c. Specialists Coordination. This plan does not apply to dental care for which in the sole opinion of the treating dentist lies outside the realm of their capacity. Practice and dentist shall coordinate with medical specialists to whom patient(s) are referred to, to assist patient(s) in obtaining specialty care. patient(s) understands that fees paid under this Agreement do not
include and do not cover specialist fees or fees due to any medical professional other than G. Curtis Croft D.D.S. Inc. and staff.


APPENDIX B

PATIENT ENROLLMENT – MEDICAL AGREEMENT FORM

Yearly or monthly fees as set out in Appendix C shall apply to the following patient(s), who by signing this Agreement, you, the patient(s) agree to the terms and conditions of the G. Curtis Croft D.D.S. Inc. Medical Agreement Form.

*All patient(s) must have a credit card or bank ACH on file to cover the cost of membership & any incidentals not covered under this Agreement. Patient(s) will approve any incidentals prior to charges.

I, the patient(s), certify that this Agreement has been read, understood and agree to the terms set forth in this Medical Agreement Form. I, the patient(s), further certify that I have received a copy of this form.

APPENDIX C

Yearly Plan: Single Member $540, Two Members $1075, Three Members $1605, Four Members $2130, Each Additional Member $520.

Monthly Plan: Single Member $50, Two Members $98, Three Members $144, Four Members $188, Each Additional Member $42.

By signing this Agreement, I, the patient(s), acknowledge that I have read, understand and agree to the terms and conditions of the Croft In-House Savings Plan/Medical Retainer Agreement.

I accept the terms and contitions above.


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Croft In-House Savings Plan - Yearly


One-Time Fee:  $0.00

Plan Price:  $0.00

Total Charged Today:  $0.00


Totals will update as members are added to your plan