ALL-IN-ONE DENTAL PLAN, INC.
This Membership Agreement (the “Agreement”) specifies the terms and conditions under which you, the undersigned member (“Member”), will be enrolled as a Member with All-In-One Dental Plan, Inc., a Florida corporation (“AIO”). This Agreement will become effective as of the date set forth by AIO at the end of this Agreement (the “Effective Date”).
1. AIO Benefits and Services. The AIO Discounted Dental Services Program (the “Program”) is available solely for patients whose dental care is not covered by any program of insurance. Other service amenities may be offered from time to time, and these may be subject to limitations.
2. Membership Fee.
Individual Individual+1 Family
$96.00/year $120.00/year $144.00/year
Individual Individual+1 Family
$15/month* $22.50/month* $30/month*
* A ONE-TIME, NON-REFUNDABLE PROCESSING FEE IS REQUIRED WITH EACH MONTHLY APPLICATION.
MEMBERSHIPS ARE FOR A PERIOD OF ONE YEAR. ANY CANCELLATION MUST BE IN WRITING AND SENT TO AIO ADDRESS AND ARE ONLY EFFECTIVE UPON RETURN OF THE AIO MEMBERSHIP CARD. A MEMBERSHIP CAN BE UPGRADED AT ANY TIME (EX: FROM INDIVIDUAL TO COUPLE, COUPLE TO FAMILY). NEW IMMEDIATE FAMILY MEMBERS CAN BE ADDED ON TO THE PLAN AT ANY TIME. TO UPGRADE YOUR DENTAL PLAN OR ADD A NEW IMMEDIATE FAMILY MEMBER, PLEASE EMAIL INFO@ALLINONEDENTALPLAN.COM OR BY CALLING US TOLL FREE AT (800) 310-BRIDGE.
3. Renewals and Termination. The annual membership fee covers a period of twelve (12) months. Failure to pay the renewal annual membership fee within 90 days from the anniversary of the Effective Date shall result in termination of your membership in the Program. (For example, if the Effective Date is May 15, 2014 then you must renew on or before February 15, 2015). You may terminate your participation at any time upon written notice to AIO. Members who terminate within the first 30 days are entitled to a full refund. Members who terminate after the first 30 days who have paid on an annual basis or advanced payments shall be entitled to a refund of any unused portion of such fees or payments. AIO may terminate this Agreement at any time on 30 days written notice to you. If AIO terminates this Agreement for any reason, you will be entitled to a prorated refund of your annual membership fee. Such prorated refund will be based on the number of days you have participated in the Program. Upon AIO’S receipt of this Agreement and the membership fee, AIO shall have the option, in its sole and absolute discretion, not to accept this Agreement and to return your payment to you (e.g., due to limitations on the number of Members).
4. Dental Care Services Excluded from Annual Membership Fee. The membership fees specified above cover only the defined AIO Amenities.
5. Dental Service Fees. AIO does not pay or receive anything in connection with the dental services fees earned by dentists participating in AIO (“AIO Dentists”). AIO has no responsibility for receiving payment from you or for paying any AIO Dentists for dental services. You agree to be personally and solely responsible for paying to each AIO Dentist who provides you dental services all fees for dental services. The dental services fees agreed upon by the AIO Dentist selected by you will be provided to you upon request. Upon paying your membership fee to AIO, you agree to accept the fee schedule provided by the AIO Dentist selected by you.
You further understand and agree to indemnify, defend and hold harmless All-In-One Dental Plan, Inc., its officers, directors, agents, employees and shareholders in connection with any costs (including attorneys fees), claims or damages of any kind which you incur or which All-In-One Dental Plan, Inc. incurs in connection with (i) the fees you incur by receiving services from AIO Dentists or their personnel, and also (ii) the services you receive from AIO Dentists and/or their personnel.
7. E-mail Communications; Privacy. If you wish to send e-mail communications to and receive e- mail responses from AIO’s dentists, staff, employees, agents and representatives, you should be aware that e-mail is not a secure medium for sending and receiving potentially sensitive personal health information. Although AIO will take steps to keep your communications with AIO and its dentists, staff, employees, agents and representatives, confidential and secure, the confidentiality of e-mail communications cannot be assured or guaranteed. You also acknowledge and understand that e-mail is not a good medium for urgent or time-sensitive communications. In the event a communication is time-sensitive, you must communicate with AIO’s dentists by telephone or in person. You acknowledge and understand that, at the discretion of AIO and/or as required by law, your e-mail communications may become part of your permanent medical record.
8. Consent. You agree to complete the Consent section below.
9. Entire Agreement. Each of the undersigned agrees to the terms of this Agreement, all of which are expressed herein. There are no promises or representations except as set forth herein.
10. Notices. Any communication required or permitted to be sent under this Membership Agreement shall be in writing and sent to the party to be so notified via certified mail, return receipt requested, or provided via hand delivery, to the addresses set forth herein. Any change in address shall be communicated in accordance with the provisions of this Section 9.
11. Governing Law. The validity, interpretation and performance of this Agreement shall be governed by the laws of the State of Florida without giving effect to the principles of comity or conflicts of laws thereof. Each party hereto agrees to submit to the personal jurisdiction and venue of the state and federal courts having jurisdiction over Broward County, Florida for the resolution of all disputes arising in connection with the interpretation, construction and enforcement of this Agreement, and hereby waives the claim or defense therein that such courts constitute an inconvenient or invalid forum.
12. Amendments and Waivers. This Agreement may only be revoked, altered, amended, or modified by the written agreement of both parties hereto. No waiver of any provisions of this Agreement shall be valid unless in writing and signed by the party against whom such waiver is sought. One or more waivers of any covenant or condition of this Agreement by any of the parties hereto shall not be construed as a waiver of any subsequent breach or of other covenants or conditions.
13. Section Headings. Any section, section title or caption contained in this agreement is for convenience only, and in no way defines, limits or describes the scope or intent of this Agreement or any of the provisions hereof.
14. Invalid Provisions. The invalidity or unenforceability of any particular provision of this Agreement shall not affect any other provision hereof. This Agreement shall be construed in all respects as if such invalid or unenforceable provisions were omitted.
15. Counterparts. This Agreement may be executed in multiple counterparts, each of which shall be deemed an original and all of which shall constitute a single Agreement.
16. Complaints. The All-In-One Dental Plan, Inc. will record all consumer complaints. A consumer may submit a complaint by emailing firstname.lastname@example.org or by calling our toll-free number at (800) 310-BRIDGE. A consumer filing a complaint will be asked what their complaint is and a company representative will investigate. All complaints will be tracked by an electronic log.
BY CHECKING THE BOX BELOW, YOU AUTHORIZE:
(i) ALL-IN-ONE DENTAL PLAN, INC., AND/OR ITS STAFF, EMPLOYEES, AGENTS AND REPRESENTATIVES, AND ALSO AIO DENTISTS TO SHARE YOUR CONFIDENTIAL PERSONAL HEALTH INFORMATION WITH OTHER TREATING DENTISTS, HOSPITALS, HEALTH CARE FACILITIES, AND LICENSED HEALTH CARE PRACTITIONERS FOR THE PURPOSE OF PERFORMING THE OBLIGATIONS UNDER THE AGREEMENT; AND
(ii) AIO OR ITS STAFF, EMPLOYEES, AGENTS AND REPRESENTATIVES, TO RELEASE ANY MENTAL HEALTH, SUBSTANCE ABUSE AND HIV/AIDS INFORMATION CONTAINED IN YOUR PERSONAL HEALTH INFORMATION, BUT ONLY IF AIO FIRST OBTAINS YOUR SEPARATE, WRITTEN CONSENT TO DO SO. ADDITIONALLY, AFTER RECEIVING YOUR CONSENT TO DO SO, AIO SHALL ONLY RELEASE SUCH MENTAL HEALTH, SUBSTANCE ABUSE AND HIV/AIDS INFORMATION FOR TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS PURPOSES.
(iii) AIO AND/OR ITS STAFF, EMPLOYEES, AGENTS AND REPRESENTATIVES, TO SEND YOUR PERSONAL HEALTH INFORMATION TO YOU VIA E-MAIL.
AIO’S POLICIES AND PRACTICES GOVERNING ITS USE AND DISCLOSURE OF PERSONAL HEALTH INFORMATION ARE AVAILABLE TO YOU UPON REQUEST, AND SUCH POLICIES AND PRACTICES MAY BE CHANGED AS NECESSARY BY AIO AS CONTAINED THEREIN. YOU MAY REQUEST THAT AIO RESTRICT THE USE OR DISCLOSURE OF YOUR PERSONAL HEALTH INFORMATION TO ONLY TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS PURPOSES. YOU MAY REVOKE THIS CONSENT AT ANY TIME BY PROVIDING WRITTEN NOTICE TO AIO IN ACCORDANCE WITH SECTION 8 OF THIS AGREEMENT. THIS AUTHORIZATION WILL REMAIN VALID DURING THE TWELVE (12) MONTH TERM OF THIS AGREEMENT AND UPON A RENEWAL OF SUCH AGREEMENT, NOT TO EXCEED TWENTY-FOUR (24) MONTHS.