KiddieKlub Dental Plan ----------------
What is the KiddieKlub Dental Plan? The KiddieKlub Dental Plan is our personally developed annual discount plan for those families that do not have any private dental insurance or a plan that is not accepted in our office. It is a plan that makes sense for today’s economy for your children to receive quality dental care. This plan is NOT dental insurance, but rather a discount plan that contains benefits and a specially designed reduced fee schedule. Where are services obtained? Services for this plan are offered at our office only. We are located at 15833 Pines Blvd, Pembroke Pines, FL 33027 How does my child receive care? Once your membership is effective you may call to schedule an appointment. We are open Monday thru Thursdays from 8:30am to 5:00pm. We offer some Friday and Saturday morning hours as well as extended hours. We will do our best to work with you to obtain an appointment that is convenient for you. Who is eligible? Children under the age of 18 are eligible to become a member of this plan. Special consideration for plan extensions after the age of 18 will be made by reason of developmental disability or physical reason or any other reason deemed acceptable to the plan by the management. When will benefits begin? Benefits will begin immediately after you enroll for the plan. Members must remain on the plan for a minimum of twelve months. The fee for the plan is as follows: First child: $199.00 per year Second child: $179.00 per year Additional chidren in same family: $169.00 per year
What are the benefits of the plan? The annual fee for the KiddieKlub Dental Plan includes cleanings (up to 2 per membership year), routine examinations (up to 2 times per membership year), x-rays, oral hygeine instructions and topical fluoride treatments (up to 2 times per membership year) at NO CHARGE. Your membership in this plan also provides you a reduced fee schedule on other services. This fee schedule is available for review when you enroll. There is a $30.00 copayment for any emergency visits. There are no deductibles or annual maximums attached to this plan such as you would find on traditional insurance plans. Additional comprehensive treatment or procedures that are recommended are provided at a reduced rate as outlined in the KiddieKlub Dental Plan fee schedule. There is also a $50.00 charge that will be assessed for broken appointments if there is not at least a 24 hour cancellation notice given.
Payment Policy
All payments are made directly to the office. The annual fee is to be collected during the first appointment for all members. Additional children in the same family who did not originally participate on the same date of their siblings and now wish to participate in the plan will have to begin their own plan for $199.00 per year. Payments for dental procedures that are based on the KiddieKlub fee schedule are due at the time of service.
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Limitations and Exlusions
1. Demonstrated non-compliance with the recommended course of treatment 2. Services which in the opinion of the attending dentist are neither necessary nor recommended for the patient’s health. 3. Restorations, splints or other appliances used to increase vertical dimension or restore occlusion 4. Any service you are referred out of the office for, Periodontics, Endodontics, Oral Surgery, Orthodontics or any other specialty. 5. Congenital malformations, except congenital anomaly of a tooth or teeth covered from birth. 6. Dispensing of drugs not normally supplied in the dental office. 7. Treatment in a hospital setting. 8. Loss or theft of space maintainers, crowns, kiddie dentures. 9.. Services that cannot be performed because of general health, physical or psychological limitations of the patient. 10. Any procedure not listed on the KiddieKlub fee schedule will be charged at 25% off usual, customary and reasonable fees. 11. KiddieKlub plan participants cannot have other dental insurance that is accepted in our office at the time of enrollment. 12. Benefits must be used during the established time period of the plan.
-------------------------------------------------------- Click here for a printable version of this form. KiddieKlub Dental Plan Enrollment Please complete the application to enroll your children in the plan.
Name:_____________________ Date :_____________________ Date of Birth:_______________ Circle One: Male or Female Address:__________________________________________________ City:_______________________ State:__________ Zip:__________ Phone:____________________ How did you find us? _____________ Email:_____________________________________________________ Additional children in your family you wish to enroll today? Name: __________________ Date of Birth:______________ Male or Female Name:__________________ Date of Birth:______________ Male or Female Name:__________________ Date of Birth:______________ Male or Female Name:__________________ Date of Birth:______________ Male or Female Payment Option #1: Credit card payment I authorize Kiddie Dental to charge my credit card a one time annual membership fee in the amount of $____________ for one year of my KiddieKlub dental plan. Circle type of card: MasterCard Visa Discover Amex Card Number: _____________ Expiration Date:___________ Signature:____________ Payment Option #2: Check payable to: KiddieDental Mail or fax your application to: KiddieDental 15833 Pines Blvd Pembroke Pines, Florida 33027 Telephone: 954-443-3030 FAX: 954-443-9431 ADA Codes for free/discounted/reduced fee services at the initial visit are as follows: 0150: Comprehensive examination 0210: Full mouth x-rays 1120: Prophylaxis child 1330: Oral hygeine instructions 1203: Topical application of fluoride child |
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KiddieDental at Westfork Dental Plaza |
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Pediatric and General Dentistry, Pembroke Pines FL |
954-443-3030 |
