DENTAL WELLNESS PLAN AGREEMENT
Well Group Inc.
Background
Well Group Inc. is a dental practice group (“Provider”) that delivers dental services through its affiliated practice locations, including AP Dental and South Boston Family Dental offices in Massachusetts and Florida. This Agreement is valid at any AP Dental or South Boston Family Dental location in Massachusetts or Florida. In exchange for certain fees, the Provider agrees to furnish the Patient with the services described in Appendix A, on the terms and conditions contained in this agreement (“Agreement”).
Definitions
1. Patient. In this Agreement, “Patient” means the person(s) for whom the Provider shall provide care, and who have signed this Agreement or are listed on the document attached as Appendix B, which is a part of this Agreement.
2. Services. In this Agreement, “Services” means the collection of services offered to you by Well Group Inc. under this Agreement. These Services are listed in Appendix A, which is attached and a part of this Agreement.
Agreement
3. NOTICE: THIS DENTAL WELLNESS PLAN AGREEMENT DOES NOT CONSTITUTE INSURANCE, IS NOT A HEALTH PLAN THAT PROVIDES HEALTH INSURANCE COVERAGE FOR PURPOSES OF THE FEDERAL PATIENT PROTECTION AND AFFORDABLE CARE ACT, AND COVERS ONLY LIMITED, ROUTINE DENTAL SERVICES AS DESIGNATED IN THIS AGREEMENT.
4. Term. This Agreement will last for one (1) year, starting on the date this Agreement is signed. The Patient’s plan benefits shall remain accessible through the end of the one-year term.
5. Renewal. This Agreement will automatically renew for successive one-year terms under the same terms and conditions, including the then-current membership fee. To cancel auto-renewal, the Patient must provide written notice to Well Group Inc. at least thirty (30) days prior to the anniversary date of the Agreement. If timely notice is not given, the Patient will be bound by the renewed term and all provisions of this Agreement, including Section 6, shall apply.
6. Cancellation; Refund Policy; Repricing of Services. This membership is annual and non-transferable. The Patient may cancel this Agreement at any time by providing written notice to Well Group Inc.
a) 30-Day Satisfaction Guarantee. If the Patient cancels within thirty (30) days of the original enrollment date and no dental services have been provided to the Patient under this Agreement during that period, the Patient shall receive a full refund of all membership fees paid.
b) Cancellation After 30 Days or After Services Used. If the Patient cancels after the first thirty (30) days, or if any dental services have been provided under this Agreement regardless of when cancellation occurs, the following repricing and settlement provisions shall apply:
(i) All dental services received by the Patient during the term of the Agreement will be repriced at Well Group Inc.’s standard usual and customary fee-for-service rates (“UCR”), as if the Patient were not a member. A copy of these fees is available upon request.
(ii) If the repriced UCR value of services received exceeds the total membership fees paid by the Patient, the Patient shall be responsible for paying the difference to Well Group Inc. within thirty (30) days of cancellation.
(iii) If the total membership fees paid by the Patient exceed the repriced UCR value of services received, Well Group Inc. shall issue a pro-rated refund of the difference to the Patient within thirty (30) days of cancellation.
(iv) Well Group Inc. reserves the right to pursue collection of any unpaid balance, including reasonable collection costs and fees.
c) Upon cancellation, all plan benefits and member pricing will terminate immediately.
7. Payments — Amount and Methods. In exchange for the Services (see Appendix A), you agree to pay Well Group Inc. a monthly or annual fee in the amount that appears in Appendix C, which is attached and is part of this Agreement.
a) If you elect annual billing, the full annual fee is due at the time of enrollment.
b) If you elect monthly billing, the first monthly payment is due at the time of enrollment, and subsequent payments are due on the same day of each following month for the remainder of the one-year term. Monthly payments represent an installment plan for the full annual obligation and do not create a month-to-month membership.
c) The Parties agree that the required method of payment shall be by automatic payment, through a debit, bank ACH, or credit card.
d) Non-payment of membership fees within 60 days of the payment due date may result in cancellation of the Agreement, at which point the repricing provisions of Section 6 shall apply.
e) Well Group Inc. reserves the right to suspend access to Services for non-payment until the account is brought current.
8. This Is Not Health Insurance. Your signature on this clause of the Agreement acknowledges your understanding that this Agreement is not an insurance plan or a substitute for health insurance. You understand that this Agreement does not replace any existing or future health insurance or health plan coverage that you may carry. The Agreement does not include hospital services, dental specialists’ services, or any services not personally provided by Well Group Inc. or its employees. You acknowledge that the practice has advised you to obtain or keep in full force, health insurance that will cover you for healthcare not personally delivered by the practice, and for hospitalizations and catastrophic events.
9. Communications. The Patient acknowledges that although Well Group Inc. shall comply with HIPAA privacy requirements, communications with the dentist using e-mail, facsimile, video chat, cell phone, texting, and other forms of electronic communication can never be absolutely guaranteed to be secure or confidential methods of communication. As such, Patient expressly waives the Provider’s obligation to guarantee confidentiality with respect to the above means of communication. Patient further acknowledges that all such communications may become a part of the dental record.
By providing an email address on the attached Appendix B and/or during online enrollment, the Patient authorizes Well Group Inc. and its owners, employees, and representatives to communicate with him/her by email regarding the Patient’s “protected health information” (PHI). The Patient further acknowledges that:
a) E-mail is not necessarily a secure medium for sending or receiving PHI and there is always a possibility that a third party may gain access.
b) Although the dentist will make all reasonable efforts to keep e-mail communications confidential and secure, neither the practice nor the dentist can assure or guarantee the absolute confidentiality of email communications.
c) At the discretion of the dentist, e-mail communications may be made a part of the Patient’s permanent dental record.
d) You understand and agree that email is not an appropriate means of communication in an emergency, for time-sensitive problems, or for disclosing sensitive information. In an emergency, or a situation that you could reasonably expect to develop into an emergency, you understand and agree to call 911 or the nearest emergency room, and follow the directions of emergency personnel.
e) Email Usage. The dentist checks e-mail frequently on weekdays during business hours. If you do not receive a response to an e-mail message by the next business day, you agree that you will contact the office by telephone or other means.
f) Technical Failure. Neither Well Group Inc. nor the dentist will be liable for any loss, injury, or expense arising from a delay in responding to a Patient when that delay is caused by technical failure, including but not limited to: failures caused by an internet service provider, power outages, failure of electronic messaging software or e-mail provider, failure of computers or computer networks, faulty telephone or cable data transmission, any interception of email communications by an unauthorized third party, or patient failure to comply with the guidelines for use of e-mail described in this Agreement.
10. Services Limited to Provider Locations. All services included in this membership plan must be performed at an AP Dental or South Boston Family Dental office operated by Well Group Inc. This plan does not cover any fees, costs, or charges generated by outside providers, offices, or specialists not affiliated with Well Group Inc., even if the Patient is referred to such providers by Well Group Inc. staff.
11. Change of Law. If there is a change of any relevant law, regulation, or rule, federal, state, or local, which affects the terms of this Agreement, the parties agree to amend this Agreement to comply with the law.
12. 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 Agreement will stay in force as originally written.
13. Reimbursement for Services Rendered. If this Agreement is held to be invalid for any reason, and the practice is required to refund fees paid by you, you agree to pay the practice an amount equal to the fair market value of the dental services you received during the time period for which the refunded fees were paid.
14. Amendment. No amendment of this Agreement shall be binding on a party unless it is in writing and signed by all the parties, except for amendments made in compliance with Section 12 above.
15. Assignment. This Agreement, and any rights you may have under it, may not be assigned or transferred by you.
16. Legal Significance. You acknowledge that this Agreement is a legal document and gives the parties certain rights and responsibilities. You also acknowledge that you have had a reasonable time to seek legal advice regarding the Agreement and have either chosen not to do so or have done so and are satisfied with the terms and conditions of the Agreement.
17. Entire Agreement. This Agreement contains the entire agreement between the parties and replaces any earlier understandings and agreements whether they are written or oral.
18. No Waiver. In order to allow for the flexibility of certain terms of the Agreement, each party agrees that they may choose to delay or not to enforce the other party’s requirement or duty under this Agreement (for example, 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.
19. Jurisdiction. This Agreement shall be governed by and construed under the laws of the state in which the Provider’s office location where the Patient primarily receives Services is situated. For patients receiving services at a Massachusetts location, this Agreement shall be governed by the laws of the Commonwealth of Massachusetts, and disputes shall be settled in the courts of proper venue and jurisdiction for that location. For patients receiving services at a Florida location, this Agreement shall be governed by the laws of the State of Florida, and disputes shall be settled in the courts of proper venue and jurisdiction for that location.
20. Service. All written notices are deemed served if sent to the address of the party written above or appearing in Appendix B by first class U.S. mail or email.
Appendix A — Services
Dental services under this Agreement are those services that the dentist is permitted to perform under applicable state law, are consistent with the dentist’s training and experience, and are usual and customary for a dental provider to provide.
STANDARD WELLNESS PLAN
Dental cleanings, exams, bitewings, Invisalign savings, 20% off additional treatment, and more.
| Benefit | Details |
|---|---|
| Routine Cleanings | Up to 2 per year |
| Dental Exams | Up to 3 per year |
| Bitewing X-ray Sets | Up to 2 per year |
| Comprehensive Invisalign® Discount | $1,000 off (once per lifetime) |
| Additional Dental Treatments | 20% off* |
| Full-Mouth X-rays | One set (once every 5 years) |
| Periodontal Evaluation | As clinically appropriate |
| Oral Cancer Screenings | As clinically appropriate |
| Fluoride Treatments | As clinically appropriate |
PERIO WELLNESS PLAN
Perio maintenance cleanings, exams, bitewings, Invisalign savings, 20% off additional treatment, and more.
| Benefit | Details |
|---|---|
| Periodontal Maintenance Visits | Up to 4 per year |
| Dental Exams | Up to 3 per year |
| Bitewing X-ray Sets | Up to 2 per year |
| Comprehensive Invisalign® Discount | $1,000 off (once per lifetime) |
| Additional Dental Treatments | 20% off* |
| Full-Mouth X-rays | One set (once every 5 years) |
| Periodontal Evaluation | As clinically appropriate |
| Oral Cancer Screenings | As clinically appropriate |
| Fluoride Treatments | As clinically appropriate |
*Discount applies to services not included in the plan benefits listed above.
NON-MEDICAL, PERSONALIZED SERVICES
Well Group Inc. shall also provide the Patient with the following non-medical services, which are complementary to our members in the course of care:
a) After Hours Access. Patients shall have direct telephone access to the dentist and/or the practice answering service seven (7) days per week.
b) E-Mail Access. Patients shall be given the practice’s e-mail address to which non-urgent communications can be addressed. Such communications shall be dealt with by the dentist or staff member of Well Group Inc. in a timely manner. Patient understands and agrees that email and the internet should never be used to access dental care in the event of an emergency.
c) No Wait or Minimal Wait Appointments. Reasonable effort shall be made to assure that the Patient is seen by the dentist immediately upon arriving for a scheduled office visit or after only a minimal wait.
d) Specialists Coordination. The practice and dentist shall coordinate with dental specialists to whom the Patient is referred to assist Patient in obtaining specialty care. Patients understand that fees paid under this Agreement do not include and do not cover specialist fees or fees due to any dental professional other than Well Group Inc. staff.
Appendix C — Membership Pricing
Annual billing saves up to 15% compared to monthly billing. Annual billing: Standard saves $80/yr; Perio saves $90/yr.
| Plan | Monthly | Annual (per mo.) | Annual Total |
|---|---|---|---|
| Standard Wellness Plan | $50/mo | $43/mo | $520/yr |
| Perio Wellness Plan | $65/mo | $58/mo | $690/yr |
All pricing is per member. Each member on a membership may be enrolled in a different plan tier. Pricing is subject to change upon renewal with 30 days’ written notice.