Legal and Disclaimers

Memberships are not insurance but a payment arrangement provided by Chestnut Dental, Inc for services rendered. Membership is not transferable to other dental offices. Payment for any cosmetic or restorative treatment is due at the time of service. Membership dues must be current in order to receive services. A lapse of 28 days in dues will require a reactivation fee of six month’s dues. Membership club discounts may not be combined with any other offers or discounts. It is solely the patient’s responsibility to schedule and keep their appointments. A patient member’s monthly agreement is with the legal entity Chestnut Dental Inc. Monthly dues and fees for dental services may change at any time. Payment management services are provided by Express ACH.

*Needed x-rays are determined by the doctor at the time of the exam.

Child Membership D0272, D1120, D1208, D0120

Perio Membership D4910, D0120, D0274

Adult Membership D1110, D0120, D0274

Benefits Overview

• No annual deductible
• No annual maximums
• No preauthorizations required
• No waiting or legibility period for major treatment
• No missing tooth clause restrictions or exclusions
• Enrollment fee for each member is non-refundable
• Enrollment fee is due at time of enrollment
• Plan effective date is at time enrollment fee is paid in full
• Plan remains active if all treatment is paid in full at time of service
• If patient is diagnosed with periodontal disease, they are not eligible for preventive treatment
• If during the plan year a patient is diagnosed with periodontal disease, the preventive plan will be prorated toward the periodontal health plan. The patient will be responsible for the difference
• Participation cannot be combined with any other offer, dental plan, or insurance
• Plan fees are based on our UCR codes and not any other dental plan fees
• Examination and radiographs are covered under emergency appointment. Patient is responsible for any other dental care completed during the visit
• Chestnut Dental Health Plan is only accepted at our office, if patient is referred to a specialist the benefits will not carry over
• Child preventive plan is for patients patients 6-months to 12 years old