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Order Information Enter Enrollment Coordinator ID or Special Promotion Code
  First name:
Middle initial:
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Birthdate: example: 7/23/1965
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Dependent First Name Last Name Date of Birth M/D/YYYY
Example 5/15/1950
Gender
1
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6
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Feel free to email us with any questions you might have.
Service@AmericasChoiceDentalPlan.com

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AGREEMENT DISCLOSURE
Terms and Conditions
You may use the dental discount referral service according to the Member Information Guide and Membership Identification Card(s). Your request for coverage authorizes America's Choice Dental to charge your credit card for the "initial down payment" to start your membership in America's Choice Dental program. America's Choice Dental will then charge your credit card each month. You must provide America's Choice Dental 30 days written notice if you wish to cancel this dental membership.

The "initial down payment" will be as follows:



Membership Monthly Billing: $14.95 per month plus $25 (a one time enrollment processing fee). Your TOTAL DOWN PAYMENT CHARGE is $39.95


AGREEMENT AND AUTHORIZATION

I/We have read, understand and agree to the terms and conditions above. I authorize the America's Choice Dental and/or assignees limited power of attorney to sign and charge my credit card according to the plan I have selected. I further authorize the Plan the authority to charge my credit card for all future monthly renewals as they come due each month. I will notify the Plan in writing of my wish to cancel the membership 30 days in advance.

Plan exclusions: (1) Work in progress is not covered. (2) Work in progress after enrollment on the dental plan must be completed before selecting another participating dentist. (3) Any dental procedures performed by a non-participating dentist are not covered. (4) Careington International cannot guarantee the continued participation of any dentist. If he/she leaves the plan, you will need to select another dentist. (5) Not all types of dentists may be available in your area; you may have to travel to receive care from a participating general dentist or specialist. (6) Some providers may charge for missed or broken appointments with no prior notice. (7) Please verify that the dentist is a participating provider when scheduling your appointment.

Thank you your information is being processed for enrollment. You will recieve a call from one of our enrollment coordinators within the next 48 hours to verify and complete the enrollment process. If you have any questions or would like to contact us to verify your enrollment call 800-591-2250.

Thank you
Cindy Rosenberg
V.P Member Services


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