Crown Dental Plan Enrollment Agreement

I wish to enroll in the Crown Dental Plan. I understand that this contract is for twelve (12) months. I am bound by that membership for the period stated and that the contract is not transferable to any other person or family member, and all fees are non-refundable. This contract shall not constitute a plan of insurance or indemnification. The plan is not responsible for any payments to your chosen dental service providers. You alone are financially responsible for all payments. Be sure you know the charges to be made for any service requested. The plan is not an employee nor an agent for any dental service providers, and as a material condition of this contract of membership you hereby agree to release the plan from any liability to you from any actions or liabilities arising in connection with the providing of any services by any dental service provider, whether referred under the plan or otherwise. All questions of the members regarding plan dentists or fee schedules should be directed to Crown Dental Plan, 1237 S Val Vista Drive Mesa, AZ 85204, (480) 964-7449. The plan shall have the right and option to change selected dentist should the dentist discontinue their agreement with Crown Dental Plan or to terminate this agreement at any time it does not have providers under this contract to provide the services intended. In the event of such termination, any fees paid shall be returned pro-rata to the person named on the plan. The plan may terminate this agreement at any time if the plan is unable to provide the services intended or comply with government regulations regarding such plans. All dentist require an initial office exam and X-rays to determine if cleanings are possible. Fee Schedule for dental procedures listed in this brochure is subject to change without notice.