On behalf of myself and my dependents (if applicable) (collectively
referred to as "Members"), I agree to the following terms and
conditions for membership in the Delta Dental Patient Direct Program
through Delta Dental of Illinois (referred to as “Delta Dental”).
1. The Delta Dental Patient Direct Program (“Program”)
offers access to a network of dentists who have agreed to provide
discounts for dental services pursuant to the Delta Dental Patient
Direct Fee Schedule. A current copy of the Delta Dental Patient
Direct Fee Schedule may be viewed and printed from the Program’s
website at
http://patientdirect.deltadentalil.com
.
Members may also contact Delta Dental of Illinois Customer Service
between 8:30 a.m. and 5:00 p.m. at 800-323-1743. The range of
discounts will vary depending on the dental service received. This
Program is not an insurance plan. Delta Dental is not an insurer,
guarantor or underwriter of any services provided under the Program.
Delta Dental shall in no event be liable for any payment to a
dentist accessed under the Program. This Program is limited to
dental services rendered in the State of Illinois and Members must
reside in the State of Illinois.
2. The dentists who participate in the Delta Dental
Patient Direct Network are independent contractors in private
practice and are neither employees nor agents of Delta Dental
and/or its subsidiaries or affiliates. The availability of any
particular Delta Dental Patient Direct Network Dentist cannot be
guaranteed, and the inclusion of any particular dentist in the
Delta Dental Patient Direct Network is subject to change without
notice.
3. Delta Dental does not provide dental treatment and is
not responsible for outcomes. All dental care is the responsibility
of the treating dentist in consultation with the Member. Selection
of the Delta Dental Patient Direct network dentist is also the
responsibility of the Member.
4. Dentists in the Delta Dental Patient Direct Network
have agreed to make certain services available to Members at the
fee level set forth in the Delta Dental Patient Direct Fee
Schedule. Members arrange for dental care and for payment directly
with the participating dentist in the Delta Dental Patient Direct
Network. Members are obligated to pay for all discounted services.
Delta Dental neither makes benefit payments to Members nor
compensates dentists for services they provide to Members. All
payments for dental services rendered are due and payable at the
time of service, unless another payment arrangement is mutually
agreed upon between the Member and the treating dentist. Members
shall be responsible for the treating dentist's office policies,
such as payment for missed appointments or late payments.
5. In order to receive services at the level set forth in
the Delta Dental Patient Direct Fee Schedule, a Member must present
his/her program ID card to the dentist's office at the time of
his/her appointment.
6. Delta Dental reserves the right to terminate a Member's
participation in the program with 30 days notice, for any reason.
7. Members have the right to cancel membership in the
Program within the first 30 days or at the end of the 12-month
membership period. If, for any reason, a Member elects to cancel
his/her membership within 30 days after receiving an ID card and
other membership materials and so notifies Delta Dental in writing,
the annual membership fee will be refunded in full.
8. A Delta Dental Patient Direct Network general dentist
may bill Members at or below the discounted fee indicated on the
Delta Dental Patient Direct Fee Schedule. For those services with a
percentage discount, a Delta Dental Patient Direct network general
dentist may bill Member his/her usual fee, discounted at 20%. Delta
Dental Patient Direct specialty dentists and orthodontists may bill
Members for his/her usual fee, discounted 20%, for all procedures
he/she performs. The usual fee is the fee most often charged and
collected by the treating dentist participating in the Delta Dental
Patient Direct Network from patients without insurance. The
recommended treatment may require the dentist to perform more than
one procedure, and as such the dentist may bill you for more than
one fee for a given course of treatment.
9. No person, other than the Member and his/her eligible
dependents, if applicable, are entitled to any rights under the
Delta Dental Patient Direct Program. Membership is not
transferable, and membership in the Program may be terminated
immediately in the event that Members or his/her dependents, if
applicable, provide any ineligible individual access to the
Member’s ID card (or otherwise provide unauthorized access to the
Program).
10. Eligible dependents under a family program include a
spouse/domestic partner and/or one or more eligible child
dependents. Eligible child dependents include the Member’s and
Member’s spouse’s, if applicable, natural born children or
stepchildren, legally adopted children, children whom the Member
and Member’s spouse have legal guardianship and who are wholly
dependent upon the Member and Member’s spouse for most of his/her
support and maintenance, and foster children. Proof of support or
adoption and all other matters pertaining to eligibility as a
dependent must be submitted to Delta Dental when requested.
11. Eligible dependent children are included under the
Member’s family membership (if selected by Members) until the end
of the calendar year in which they attain the age of 26.
12. A child otherwise defined above but who has obtained
age 26 and who Delta Dental determines is incapable of
self-sustaining employment by reason of mental or physical handicap
or developmental disability shall be considered a child under this
program if he/she depends on the Member or the Member’s spouse for
support and maintenance and had the condition before attaining age
26. Proof of disability must be submitted to Delta Dental of
Illinois when requested.
13. The Delta Dental Patient Direct Program does not apply
to any dental treatment the Member elected and received or began
prior to the date the Member notified the Delta Dental Patient
Direct Network Dentist (by presenting his/her membership ID card)
of his/her membership in the Program. Any procedures performed by a
dentist who does not participate in the Delta Dental Patient Direct
Network are not included in the Program. Any Member accepted for
orthodontic treatment must remain a Member of the Delta Dental
Patient Direct Program for the full duration of his/her treatment
or risk additional charges from his/her network orthodontist.
14. Members who have dental insurance are not eligible for
the Delta Dental Patient Direct Program. The Delta Dental Patient
Direct Program cannot be used in connection with any dental
insurance or benefit coverage, including Delta Dental, and cannot
be used in connection with any other type of insurance, including
but not limited to medical and accidental injury insurance. The
Delta Dental Patient Direct Program does not coordinate benefits
with any insurance or benefit programs. Delta Dental has the right
to confirm Members are not currently enrolled in any other Delta
Dental program.
15. Delta Dental has no liability for providing and does
not guarantee dental services, and is not liable for the quality of
any dental services rendered.
16. This Delta Dental Patient Direct Program is only
available if included services are performed by a participating
dentist in the Delta Dental Patient Direct Network. It is the
Member’s responsibility to ensure the dentist is participating in
the Delta Dental Patient Direct Network even when referred by a
network dentist to a specialist or to another dentist. A listing of
current network dentists, including network participating
specialists may be found at
http://patientdirect.deltadentalil.com.
Please note that dental offices participate in various Delta Dental
programs. If a Member calls an office that he/she believes is
participating in the Delta Dental Patient Direct Network (always use
the specific term “Delta Dental Patient Direct” not the general term
“Delta Dental’) and that office indicates it does not participate in
the network, immediately call Delta Dental Patient Direct customer
service at 800-323-1743. (Please be aware of the fact that not all
of the dentists in a dental practice may participate in the Delta
Dental Patient Direct Network; it is best to be specific when
calling to ask about network participation.)
17. Applications, along with the applicable membership
fee, must be received by the 20th of the month to be effective the
1st of the following month (i.e., applications submitted on
February 19 will be effective March 1). Applications received after
the 20th will be effective the first of the month after the next
month (i.e., applications submitted on February 21 will be
effective April 1). The annual membership fee can only be paid by
credit card. Notification of the effective date will be emailed
with a welcome packet and ID card(s).
18. The Delta Dental Patient Direct Fee Schedule is
subject to change by Delta Dental. Changes shall not occur more
than once per calendar year.
19. All applicants for membership must be 18 years or
older. Parents can enroll a dependent child, but payment by credit
card (the credit card holder) must be made by an individual 18
years or older.
20. By signing the attached application, the Member
acknowledges that the Member has read and understands the above
terms and conditions and agrees to abide by them.
21. Communications to Delta Dental of Illinois with
respect to the Delta Dental Patient Direct Program shall be sent
via email to:
patientdirect@deltadentalil.com,
or to the following mailing address:
Delta Dental of Illinois
Attn:Patient Direct
111 Shuman Blvd.
Naperville, IL 60563
22. Communications to Delta Dental regarding complaints with respect to the Delta Dental Patient Direct Program shall be sent via email to: compliance@deltadentalil.com, or to the following mailing address:.
Delta Dental of Illinois
Attn:Patient Direct
111 Shuman Blvd.
Naperville, IL 60563
Telephone 800-323-1743
OR
Illinois Department of Insurance
320 W. Washington Street
Springfield, IL 62767-0001
Telephone (217) 782-4515