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Direct Access is an annual membership. If you choose to pay monthly, a $20 setup fee will be charged. If you choose to pay annually, the setup fee is waived.

Name

Home Address (Please do not use the # symbol, to enter a unit number, please use Suite, Apt. or Unit)

Billing Address (Please do not use the # symbol, to enter a unit number, please use Suite, Apt. or Unit)

Date of Birth:

I want my spouse on this plan I want my child(ren) on this plan (under 65 only)



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I agree to the terms and conditions listed below

This Fee-for-Service Discount Plan Membership Agreement (the "Agreement) is entered into by and between Direct Access Plans, LLC, a Utah limited liability company ("DA"), and the individual whose name and address are herein set forth (the "Member"), on the date the terms and conditions are accepted, with privileges effective as of the date payment of the membership fee is received by DA (the "Effective Date"). The parties agree that in consideration of payment by Member of the annual membership fee, DA will make available to Member as of the Effective Date the privileges of the Direct Access Fee-for-Service Discount Plan (the "Plan"). Depending on the plan options selected herein and paid for by Member, privileges may include discounts from participating providers ("Providers") of dental, vision, hearing and/or prescription medication services ("Services"). The Plan's Providers and Services are set forth in the New Member Packet, a copy of which is also available on-line at the DA website www.dentistdirectaccess.com. Member understands and agrees that the Providers and Services may change from time to time, as reflected in the updated version of the Provider Panel on the DA website. The term of this Agreement is for one (1) year from the Effective Date, and will be automatically renewed for additional one year terms unless either party sends a written termination that is received by the other party at least 10 days before the end of the current term. Notices shall be sent to the parties' respective addresses as set forth herein or to such other address as a party shall hereafter specify in writing.

By completing the payment section the Member hereby authorizes DA to initiate credit entries and if necessary, debit entries and adjustments for any credit entries in error with respect to Members account/designated method of payment. The authorization shall remain in full force and effect until DA has received written notification from Member of its termination in such time and in such manner as to afford DA a reasonable opportunity to act on it.

This program is not insurance. This program offers discounts only at participating Providers and the Member is responsible to pay the discounted fees negotiated with Providers. For Utah this plan is administered by Dentist Direct, LLC located at 801 N. 500 W. Ste. 300, Bountiful, UT 84010. (866)696-6527. All other states: Careington International Corporation, 7400 Gaylord Parkway, Frisco, TX 75034; phone 800-372-7615

The Member may rescind this Agreement by sending written notice to DA within 30 after the effective date or receipt of membership materials (whichever is later). Member understands and agrees that after the 30-day recession period, the membership fee becomes non-refundable. If Member has elected to pay in monthly installments, an early termination fee in the amount of Member's annual membership fee (less monthly installments already paid) shall become due in full if the Member chooses to terminate the membership for any reason before the end of the term. The administrators have no liability for providing or guaranteeing service or the quality of service rendered by Providers.