MDP Member Agreement

MAINLINE DENTAL PLAN, INC. ®
9 Furler Street , Totowa, NJ 07512
Phone: 1- 877- 880- PLAN (7526) Fax: (702) 880-7531

MEMBERSHIP AGREEMENT

This agreement dated _____________________________ between Mainline Dental Plan, Inc. (MDP, Inc.) and ____________________________________________ (primary member name) entitles member to dental care services for the reduced fees as listed in the Fee Schedule in accordance with the following terms and conditions:

Member must remain in MDP, Inc. for a minimum if 12 months, and agrees to pay annual fee at inception of Membership.
Member understands that these reduced fees are only valid if treatment is provided by a licensed participating MDP, Inc. dentist.
Member understands that if annual payment is not current, treatment will not be provided at the MDP, Inc. fees until membership payment is made current. If MDP, Inc. membership is terminated, plan fees are no longer in effect and Member is responsible for entire dentist's fee.
Membership will be renewed on an annual basis.
MDP, Inc. reserves the right to review fees and adjust accordingly every two (2) years. Member has the right to terminate membership at that time without any penalties.
Payment must be made to the MDP, Inc. participating Dentist when services are rendered unless other financial arrangements have been made in advance and member's signature is on file agreeing to payment terms.
Treatment must be started and completed while Member is enrolled in MDP, Inc.

ANNUAL MEMBERSHIP FEES

Single Member	$102.00
Member & Spouse (or domestic partner)	$132.00
Parent/Child	$132.00
*Family	$156.00

*Family includes: Member, spouse and all dependent children under 18 years of age.

PLEASE PRINT:
Primary Participant's Name _____________________________________________________ Male/Female __________
Address ___________________________________________________________________________________________
City ____________________________________ State _______________________ Zip _____________
Date of Birth ______________________________
Home Telephone Number ______________________ Work Telephone ___________________
E-Mail Address _________________________________________

LIST OF HOUSEHOLD MEMBERS TO BE INCLUDED IN PLAN:

Name _________________________________________________________________ Date of Birth ______________
Name _________________________________________________________________ Date of Birth ______________
Name _________________________________________________________________ Date of Birth ______________
Name _________________________________________________________________ Date of Birth ______________

(list additional household members on the next page)

Primary Participant Signature _____________________________________________ Date ________________
MDP, Inc. Representative Signature ________________________________________Date ________________
MDP, Inc. Representative ID #__________

An executed copy of Membership agreement will be mailed to you along with your Membership card.
Please see next page for payment information.

LIST OF ADDITIONAL HOUSEHOLD MEMBERS TO BE INCLUDED IN PLAN:

Name _________________________________________________________________ Date of Birth ______________
Name _________________________________________________________________ Date of Birth ______________
Name _________________________________________________________________ Date of Birth ______________
Name _________________________________________________________________ Date of Birth ______________

MDP, Inc. accepts the following payment types: (please do NOT send cash)

Personal checks or money orders made payable to MDP, Inc.
Major Credit Cards

If paying by Credit Card:

Card Type:	____Visa
	____MasterCard
	____Discover
	____American Express

Card # ___________________________________________________________________
Name on Card _____________________________________________________________
Expiration Date __________________________________

Signature: _____________________________________________________

Annual Membership Fee must be paid in full.

REFERRALS

MDP, Inc. offers affordable dental care to people like you. If you know someone in need of affordable dental care and would like to offer this opportunity to them, please fill out this referral form and we will contact them.

Name _______________________________________________________________
Address ______________________________________________________________
City _____________________________ State ____________ Zip ________________
Telephone # (optional) ___________________________________________