Lookup - Quality Network Plans - providing savings to groups and individuals since 1994

JOIN

I would like to join this plan. I understand that this plan is not insurance. It is a reduced-fee-for-service program, and I am responsible for payment of services rendered by providers at the time of service.

All fields are mandatory:

E-Mail:

Mr Ms Mrs Miss

First and Last Name:

Street Address:

City:

State:

Zip Code:

Telephone:

Type of Plan:

	Single	$6.00/month
	Household	$10.50/month
	Single	$60.00/year
	Household	$99.00/year

Payment Type:

		VISA
		Master Card
		American Express
		Discover

Credit Card Number:

Expiration Date:

For monthly payment, please charge my credit card each and every month in accordance with my selection above for the amount indicated for as long as I am a plan member. The first monthly charge will include the non-refundable one-time $15.00 application fee. If you also purchase the ID Theft Protection program there will be only one application fee charged.

For yearly payment, please charge my credit card each and every year in accordance with my selection above for the amount indicated for as long as I am a plan member. The first yearly charge will include the non-refundable one-time $15.00 application fee. If you also purchase the ID Theft Protection program there will be only one application fee charged.

I permit National Benefit Builders, Inc. (NBBI) to charge my credit card for these amounts. I understand that this plan is not insurance, and that payment for services rendered by providers is due at the time of service.

I permit National Benefit Builders, Inc. (NBBI) to charge my credit card for these amounts. I understand that this plan is not insurance, and that payment for services rendered by providers is due at the time of service.

Disclosures:
  1)  The DentAchoice plan is not a health insurance policy.
  2)  The DentAchoice plan provides discounts at certain health care providers for medical services.
  3)  The DentAchoice plan does not make payments directly to the providers of medical services.
  4)  The DentAchoice plan Participant is obligated to pay for all health care services but will receive a discount from those health care providers who have contracted with the AccessOne. Access One Consumer Health, Inc. is located at 84 Villa Rd., Greenville, S.C. 29615. Telephone 800-896-1962 www.accessonedmpo.com

You may terminate participation in the first 45 days after receipt of ID card and receive a full refund on any fees or dues paid, less a processing fee. After the first forty-five (45) days, you may cancel participation at any time. The DentAchoice must receive notification at least five (5) business days in advance of the next billing cycle for You not to be charged for that billing cycle.

This program and the program administrators have no liability for providing or guaranteeing service or any liability for the quality of service rendered.

  I agree with the terms and conditions above.


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