DENTAL RETAINER AGREEMENT 

Background

Haven Dental Center is a Direct Primary Care dental practice (“DPC”), which delivers dental services at 2685 N 1000 W, Pleasantview, Utah 84414. In exchange for certain fees, the practice agrees to provide you with the services described in Appendix A on terms and conditions contained in this agreement (“Agreement”).

Definitions

1. Patient. In this agreement, “Patient” means the person for whom the dentist 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 Haven Dental in this Agreement. These services are listed in Appendix A, which is attached and a part of this Agreement.

Agreement

3. NOTICE: THIS MEDICAL RETAINER AGREEMENT DOES NOT CONSTITUTE INSURANCE, IS NOT A MEDICAL PLAN THAT PROVIDES HEALTH INSURANCE COVERAGE FOR PURPOSES OF THE FEDERAL PATIENT PROTECTION AND AFFORDABLE CARE ACT AND COVERS ONLY LIMITED, ROUTINE HEALTH CARE SERVICES AS DESIGNATED IN THIS AGREEMENT.

4. Term. This Agreement will last for (1) one year, starting on the date this Agreement is signed.

5. Renewal. The Agreement will automatically renew each year on the anniversary date of the Agreement, unless either party cancels the Agreement by giving thirty (30) days prior written cancellation notice.

6. Termination. Regardless of anything written above, you will always have the right to cancel this agreement. Either party can end this agreement at any time by giving the other party thirty (30) days prior written notice.

7. Payment and Refunds – Amounts and Methods. In exchange for the Services (see appendix A1), you agree to pay Haven Dental Center, a monthly or annual fee in the amount that appears on appendix C, which is attached and is part of this Agreement.

a) this monthly or annual fee is payable on a prorated basis when you sign the Agreement and is due on the 1st (or on the day you signed up) business day of each month or each year thereafter.

b) the Parties agree that the required method of monthly or annual payment shall be by automatic payment, through a debit, Bank ACH, or credit card.

c) If this agreement is cancelled by either party before the agreement ends, Haven Dental or it’s designee will review and settle your account as follows:

•  i) We will refund you the unused portion of your fees on a per diem basis; or
•  ii) If the value of the Services you received over the term of the Agreement exceeds the amount you paid in membership fees, you shall reimburse Haven Dental in an amount equal to the difference between the value of Services received and the amount you paid in membership fees over the term of the Agreement. The Parties agree that the value of the Services is equal to the practice’s usual and customary fee-for-service charges. A copy of these fees is available on request.

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 Haven Dental Center 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 Haven Dental Center 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 communications. As such, patient expressly waves the Dentist’s and/or Haven Dental Center’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 medical record.

By providing an email address on the attached Appendix B and/or during online enrollment, the Patient authorizes Haven Dental Center, and it’s owners, employees, and representatives to communicate with him/her by E-mail 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 and/or Haven Dental Center 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 E-mail communications;

(c) At the discretion of the dentist, E-mail communications may be made part of Patient’s permanent medical record; and,

(d) You understand and agree that an E-mail 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) E-mail Usage. The dentist and/or Haven Dental Center 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 dentist or Haven Dental Center by telephone or other means.

(f) Technical Failure. Neither Haven Dental Center nor the dentist will be liable for any loss, injury, or expense arising from a delay in responding to Patient, when that delay is caused by technical failure. Examples of technical failures include 

(i) failures caused by an internet service provider

(ii) power outages

(iii) failure of electronic messaging software, or email provider

(iv) failure of the practices computers or computer network, or faulty telephone or cable data transmission

(v) any interception of email communications by a third party which is unauthorized by the practice

(vi) patient failure to comply with the guidelines or use of email described in this agreement

10. Dentist Absence. From time to time, due to vacations, illness, or personal emergency, the dentist may be temporarily unavailable to provide the Services referred to above in this Agreement. In the event of the dentist’s absence during usual clinic hours, patients will be given the name and telephone number of an appropriate provider for the patient to contact.

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 or competent jurisdiction, that part will be amended to the extent necessary to be enforceable, and the remainder of the contract 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 or medical 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.

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 party certain rights and responsibilities. You 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 Parties 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 and construed under the laws of the State of Utah. All disputes arising out of this agreement shall be settled in a court of proper venue and jurisdiction for Pleasantview, Utah.

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.

APPENDIX A – SERVICES

1. Dental services. Dental and medical services under this Agreement are those services that the dentist is permitted to perform under the laws of the State of Utah and are consistent with the dentist’s training and experience, are usual and customary for a dental physician to provide, and include the following:

Dental Membership Plan

• 1 Periodic Exam
• 1 Comprehensive Exam
• 1 Emergency Exam
• 2 Cleanings
• 2 Fluoride Treatments
• 2 Oral Cancer Screenings
• 2 Periodontal Screenings
• All Required X-Rays*
• 10% Off Clear Braces
• 20% Off Additional Treatments

Perio Membership Plan

• 1 Periodic Exam
• 1 Comprehensive Exam
• 1 Emergency Exam
• 4 Periodontal Maintenance
• 2 Fluoride Treatments
• 2 Oral Cancer Screenings
• 2 Periodontal Screenings
• All Required X Rays*
• Initial Scaling and Root Planing
• 10% Off Clear Braces
• 20% Off Additional Treatments

*does not include 3D imaging

2. Non-Medical, Personalized Services. Haven Dental Center shall also provide Patient with the following non-medical services (“Non-Medical Services”), which are complementary to our members in the course of care: 

1. After Hours Access. Patient shall have access to dentist and or the practice answering service seven days per week.
2. E-mail Access. Patient shall be given the practices E-mail address to which non urgent communications can be addressed such communication shall be dealt with by the dentist or staff member of a dental center in a timely manner. Patient understands and agrees that E-mail and the Internet should never be used to access medical care in the event of an emergency, or any situation that patient could reasonably expect may develop into an emergency.

Patient agrees that in such situations when a patient cannot speak to the dentist immediately in person or by telephone, the Patient shall call 911 or the nearest emergency medical assistance provider and follow the directions of emergency medical personnel.

1. No Wait or Minimal Wait Appointments. Reasonable effort shall be made to ensure that patient is seen by the dentist immediately upon arriving for a scheduled office visit or after only a minimal wait.
2. Specialist Coordination. Practice and dentist shall coordinate with medical specialists to whom Patient is referred to assist Patient in obtaining specialty care. Patient understands that fees paid under this Agreement do not include and do not cover specialist fees or fees due to any medical professional other than Haven Dental Center.

APPENDIX B 

PATIENT ENROLLMENT – MEDICAL AGREEMENT FORM

Annual and monthly fees as set out in Appendix C shall apply to the following Patient(s), who are either signing below or have authorized representative signing for them, and agree to the terms and conditions of the Haven Dental Center Medical Agreement Form: 

* All Patients must have a credit or debit card on file to cover the cost of membership in any incidentals not covered under the Agreement.

I certify that I have read, understand, and agree to the terms set forth in this Medical Agreement Form. I further certify that I have received a copy of this form.

APPENDIX C

MEMBERSHIP PRICE

Dental Membership Plan

• Single: $350/year or $35/month
• Dual: $700/year or $70/month
• Family (3): $1000/year or $100/month
• Family (4+): $1000/year + $200/year/additional member 

Perio Membership Plan

• Individuals: $800/year or $80/month