By completing and signing this Enrollment Form, and paying the annual enrollment fee (“Membership Fee”), the patient (“You”) acknowledges that You have read and agreed to the following terms and conditions (this “Agreement”) of the FlossClub (the “Plan”). Important additional information regarding the Plan is available on the FlossNYC website at flossnyc.com (the “Website”).
ENROLLMENT AND PAYMENT; AUTOMATIC ANNUAL RENEWALS
You are currently enrolled for one (1) year from the effective date of enrollment (the "Enrollment Term”). If you have paid the annual Membership Fee by credit card, then FlossNYC will bill your credit card for the Annual Membership Fee as follows: the annual Membership Fee of $360.00 will be billed to you upon initial enrollment and each annual renewal. The Plan will automatically renew your membership at the end of each Enrollment Term on an annual basis, and your credit card will be automatically charged the annual renewal Membership Fee as described above, unless you cancel your enrollment in the Plan as provided below at least thirty (30) days prior to the expiration date of the then current Enrollment Term. The expiration date of the then current enrollment Term shall be the last day of the month which is one year from the month in which you initially enrolled in the Plan. If you have paid the initial membership fee by check, then your enrollment will expire at the end of the enrollment Term, unless you renew your enrollment and pay the annual Membership Fee payable for the next Enrollment Term. Your renewal and payment must be received by FlossNYC at least two (2) weeks prior to the expiration date of the then current Enrollment Term in order to avoid interruption of your membership in the Plan. Any checks returned as unpaid will result in a $25 service charge.
FlossNYC reserves the right to charge new members a one-time processing fee upon enrollment or annual renewal of the Plan (“Processing Fee”). The Processing Fee, if any, will be posted on the Website and billed upon your initial enrollment or annual renewal, as the case may be. FlossNYC reserves the right to increase its annual Membership Fee from time to time for a future Enrollment Term. Any such increase in fees will be posted on the Website and will become effective as of January 1 of each year in which such increase shall apply.
You hereby authorize FlossNYC to bill and receive payment for the initial Membership Fee, Processing Fee, if any, and renewal Membership Fees, as set forth in this Agreement. If your credit card or billing information changes during an Enrollment Term, it is your responsibility to provide updated information to FlossNYC on a timely basis. If your credit card is declined more than two times in any annual Enrollment Term, you will be charged a $25 service charge.
PLAN DESCRIPTION; CREDITS FOR COMPLIMENTARY MEMBER SERVICES
The Plan is a prepaid discount membership program for dental services that is being offered by FlossNYC. In addition to Ragini Singla DMD P.C. d/b/a FlossNYC (“FlossNYC”), certain dentists and dental practices have contracted with FlossNYC to be participating providers (“Providers”) under the Plan to provide certain specified dental services (“Covered Services”) for the discounted fees. A list of Plan Providers (“Provider List”) and a discounted fee schedule (“Fee Schedule”) for each Provider are available on the Website. Such discounted fees are provided at predetermined rates and at a percentage off the Providers’ usual and customary rates (“UCR”) for such designated dental services. Providers have further agreed to charge You the discounted fees listed in the Fee Schedule for treating You for any complications that may occur in their providing Covered Services for You.
When selecting a Provider under the Plan, You are required to confirm that such Provider is then a current Provider under the Plan and that his or her Fee Schedule is up to date. At the time of your appointment you are required to present your Member ID Card to the Provider, and You are obligated to pay the Provider directly for all the non-covered and Covered Services he/she provides for You, including any sales or use taxes imposed upon the services; however, for Covered Services, and complications with Covered Services, You will be charged the discounted fees listed in the Provider’s Plan's Fee Schedule.
Included with the annual Membership Fee are membership credits (“Credits”) to be used by each Enrolled Patient for certain complimentary member services offered by the Plan from time to time (collectively, “Complimentary Member Services”), which Complimentary Member Services at the date hereof include: (i) two (2) teeth cleanings per person per Enrollment Term in the Basic Plan, or four (4) teeth cleanings per person per Enrollment Term in the Premium Plan (adult or children) to be provided by FlossNYC, to provide teeth cleaning services, (ii) an annual examination per Enrollment Term, and (iii) a full set of intraoral x-rays per Enrollment Term (panoramic and occlusal x-rays are subject to payment of additional discounted fees). Credits shall be issued for a particular Complimentary Member Service and are non-transferable. The Complimentary Member Services may be modified by the Plan from time to time, and any such modifications will be posted on the Website; provided, however, that any Complimentary Member Services offered for the then-current Enrollment Term shall remain in effect for the balance of such Enrollment Term so long as You are current in the payment of your Membership Fee. To use your Credits, simply contact FlossNYC, identify yourself as an Enrolled Patient in the Plan, and schedule your appointment for the Complimentary Member Services. If you have available Credits for the Complimentary Member Services you schedule during your Enrollment Term, then FlossNYC shall accept your Credits as payment for such services and will not bill you for such Complimentary Member Services. If all Complimentary Member Services allotted for an annual Enrollment Term are not used by You, they may NOT be carried over to any subsequent Enrollment Term, shall not be transferable to any other person, and You shall not be entitled to receive a refund of any portion of your Membership Fees. If you wish to receive additional Complimentary Member Services beyond your annual allotment, you may purchase additional Credits from FlossNYC. If you schedule an appointment for any Complimentary Member Services and fail to cancel your appointment in accordance with the cancellation policies of FlossNYC, then that appointment shall count as one of your annual allotted Complimentary Member Service(s) under the Plan.
LIMITATIONS, EXCLUSIONS & EXCEPTIONS
Not all dental services are Covered Services under the Plan. Only those listed in the Fee Schedule are Covered Services being provided by Providers for the discounted fees listed in the Fee Schedule.
FlossNYC reserves the right to change, modify or make substitutions in the Provider List, the Covered Services, and the Fee Schedule for Provider services, at any time, and from time to time, without notice, during the Enrollment Term. FlossNYC will endeavor to reflect such changes on the Website from time to time.
If you require any dental services that are not Covered Services, then, under the Plan, Providers have agreed to charge You their usual and customary rates (“UCR”) that they charge their other patients for providing such non-covered services. You must consult with the Provider for his/her UCR fee schedule for such non-covered services.
FlossNYC_ has chosen to work with a select number of specialists in the New York City area as Providers in the Plan. FlossNYC will endeavor to keep the Provider List and Fee Schedule up to date such that only participating active Providers are listed on the Website. FlossNYC relies on updated information from its participating dental providers, and there can be no assurances that such Provider List or Fee Schedule are current at any given time. FlossNYC strongly recommends that You confirm that a Provider is currently a Participating Provider before You seek out and receive any services from that Provider.
Not all Providers will provide all the Covered Services listed in every Fee Schedule. It is your responsibility to determine, prior to receiving any treatment/care, those Covered Services that the Provider You select is providing under the Plan.
If the Provider from whom You are receiving dental services terminates his/her participation in the Plan, then that Provider may have agreed to complete any treatment plan then in progress for You. Once your ongoing treatment plan is complete, or if such Provider is unable to continue with your treatment for any reason, You will have to select another Provider in order to continue to receive the discounted fees listed in the Plan's Fee Schedule for Covered Services.
The Plan is not an insurance plan and is not intended to replace dental insurance. It is not a Qualified Health Plan under the Affordable Care Act or a Medicare Prescription Drug Plan. The Membership Fee is not an insurance premium. Neither the Plan nor FlossNYC are licensed insurers, health maintenance organizations, or other underwriters of health care (dental) services.
Your selection of a Provider is your responsibility and is not based on any representations made by FlossNYC. Participating Providers are independent contractors and are neither employees nor agents of FlossNYC or its affiliates. FlossNYC cannot guarantee the continued participation of any Provider. Providers are subject to change without notice, and if a Provider leaves the Plan, you will need to select another Provider. FlossNYC does not, and cannot, guarantee that any particular dentist or dental practice will become, or will continue, as a Provider under the Plan for any period of time. Under the Provider Participation Agreement any Provider may terminate its participation in the Plan upon advance notice to FlossNYC. In addition, FlossNYC reserves the right to terminate the participation of any Provider from the Plan.
Providers are solely responsible for the professional advice, treatment and care, as well as the overall quality and outcome, of the dental services they provide for You. Neither the Plan nor FlossNYC make any representation, warranty, or guaranty regarding any aspects of the dental services, or the quality or outcome of such services furnished by Providers. Neither the Plan nor FlossNYC has any responsibility or liability to You with regard to any of these matters, and You must address all of them solely with the Providers who treated You.
You acknowledge that FlossNYC is solely a service provider that offers members access to participating dentists who provide dental services at discounted rates to Plan participants and that FlossNYC is not licensed to, and does not, provide dental services of any kind. Accordingly, You, for yourself and each of your family members enrolled in the Plan as part of your enrollment, as the case may be, hereby forever releases and discharges FlossNYC and its officers, directors, members, agents, employees and affiliates from any and all liabilities, claims, demands, actions and causes of action, whatsoever, that You or such family member may have by reason of any damage or personal injury sustained as a result of or in connection with any dental services provided to You or your family member by a Provider. Your sole recourse against FlossNYC shall be cancellation of your enrollment in the Plan pursuant to this Agreement.
Any notices required to be given by FlossNYC may be given by posting on the Website.
You have the right to cancel your enrollment in the Plan at any time during the initial thirty (30) days of any Enrollment Term, and You will receive a full refund of your Membership Fee for that Enrollment Term; provided, however, that if you have sought and received treatment for any Covered Services or any Complimentary Member Services during such thirty (30) day period, then you shall not have the right to cancel your enrollment in the Plan until the expiration of the then-current Enrollment Term. The one-time Processing Fee is non-refundable. You can cancel your enrollment by email using the Website. If You cancel your enrollment after the initial thirty (30) day period, then your cancellation will be effective at the end of the Enrollment.
FlossNYC reserves the right to terminate your enrollment in the Plan at any time for any reason, including for the non-payment of your Membership Fee. If FlossNYC terminates your enrollment for any reason, other than the non-payment of your Membership Fee, then FlossNYC may provide a refund on a case-by-case basis.
If You have any complaints about how FlossNYC is administering/operating the Plan, You can submit the complaint by email at firstname.lastname@example.org. FlossNYC will make every reasonable effort to respond to your complaint, by email within fourteen (14) days after it is received.
If your complaint is about the dental services provided by a Provider, the fees you were charged, or any other dissatisfaction with a Provider, all such complaints must be addressed directly with the Provider. To file a complaint about the professional conduct of a New York dentist or about someone who is practicing without a license, e-mail email@example.com or call 1-800-442-8106, or the Manhattan regional office at 212-961-4369.
Any dispute between FlossNYC and You regarding enrollment in or administration of the Plan shall be resolved only through final and binding arbitration through the arbitration services provided by the Judicial Arbitration and Mediation Services (“JAMS”), 45 Broadway, New York, NY 10006 (212-751-2700). The arbitrator shall have substantial experience in “reduced fee for service” matters in New York State. The decision of the arbitrator shall be final and binding on the Parties. If FlossNYC shall be the prevailing party in such arbitration action, then You shall pay to FlossNYC all of FlossNYC’s reasonable attorneys’ fees, expert fees, and other costs and expenses of the arbitration. You acknowledge and agree that, under this provision for arbitration, You are giving up your rights to pursue any such disputes/controversies through a lawsuit in a court of law with a judge and jury. Specifically, You are giving up your rights to have any such disputes/controversies decided by a jury and, instead, You agree to have them decided solely by an arbitrator.
Enrollment and membership in the Plan is for your own personal benefit and may not be assigned or delegated by You to any other person. Your violation of this provision may, in the discretion of FlossNYC, result in immediate termination of your Plan membership for cause.
This Agreement, along with the Enrollment Form, shall constitute the entire agreement and understanding by FlossNYC and You with regard to your enrollment in the Plan. No other representation, inducement or promise shall be of any force or effect.
This Agreement shall be governed by and construed in accordance with the internal laws of the State of New York, regardless of any principles regarding conflicts of laws.
This Agreement may be executed by electronic signature, which signature shall make this Agreement a binding original document with the same force and effect as if signed manually by the undersigned.
Should You have any questions regarding your enrollment in, or use of the Plan, please call us at (212) 486-7574 between the hours of 8:30 AM and 6:00 PM Monday through Thursday. Any written notices or inquiries should be addressed to FlossNYC as follows: FlossNYC, 30 Central Park South, 7D, New York, NY, 10019.
I acknowledge that I have read this Agreement; that I understand it; that any questions I may have had about it have been answered to my complete satisfaction; and that I have voluntarily signed this Agreement.
FlossNYC - Copyright 2019
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