dental - Lee Dental Centers

DENTAL
PASSPORT
We make
Modern Dentistry
affordable!
ARE YOU TIRED OF....
Confusing dental fees?
Dental Passport has up front easy to understand
discounted fees.
Not getting coverage on the dentistry you WANT?
With Dental Passport, cosmetic dentistry is included,
including our most popular whitening options.
Postponing the treatment you need because of
dental benefit maximums and “waiting periods”?
With Dental Passport, there are NO annual maximums
and NO waiting periods, so you can get the the
treatment you need before things get worse.
Your dental insurance telling you what is necessary?
Dental Passport puts the decision making back where
it belongs – between you and your dentist.
DENTAL PASSPORT PLAN
Annual Fee
UNINSURED
You only
$96 ($8/month)
You and your spouse
$132 ($11/month)
You and eligible family members $156 ($13/month)
INSURED
(See Section 19)
$60 ($5/month)
$72 ($6/month)
$90 ($7.50/month)
Discount Plan
LEE DENTAL PASSPORT is a membership
plan that gives you access to discounted
dental services with participating dentists.
AFFORDABLE
• For as little as $5 a month you can gain access
to discounted popular dental services
• Annual fees range from $5/month - $13/month.
ACCESSIBLE
• Participating dentists throughout the
San Antonio area
• If you don’t have dental insurance, it gives you
access to discounts of up to 40%
• Can also be combined with most dental
insurances to help with non- covered or
excluded services
SIMPLE DENTISTRY
• No annual maximums
• No frequency limitations
• Cosmetics included (even tooth whitening)
• Even implants are discounted
Offered by:
DENTAL
PASSPORT
Discount Plan
Leon Springs
24051 IH 10 West
Universal City
24051 IH 10 West
Northwest
6336 Bandera Rd
Northern Hills
12175 Nacogdoches
Southwest
6527 SW Military
Southeast
4135 E. Southcross
All porcelain crown
*with general dentist
$1080
$864
$216
Dental Passport Discount Plan
Member Name: ______________________
Effective Date: _______________________
Plan type:
INDIVIDUAL COUPLE
FAMILY
All locations: 210-681-3555
leedentalcenters.com
ORAL SURGERY
EXTRACTION – SIMPLE
EXTRACTION – COMPLICATED/SURGICAL
BONE GRAFT/SOCKET PRESERVATION – PER SITE
ORTHODONTICS
LIMITED ORTHODONTIC TREATMENT – PROBLEM FOCUSED
COMPREHENSIVE ORTHODONTIC TREATMENT
RETAINERS/RETENTION
ADDITIONAL SERVICES
NITROUS OXIDE GAS
IN-OFFICE PROFESSIONAL TOOTH WHITENING
(UPPER AND LOWER)
TAKE HOME CUSTOM TOOTH WHITENING
(UPPER AND LOWER)
Apt.
$144.00
$234.00
$495.00
$1800.00
$4410.00
$600.00
$60.00
$440.00
$220.00
Date
Authorization Signature
X
CVV2 Number:
Uninsured
Insured
$ 60.00 $
Individual................................
$ 96.22
Couple................................... $132.22
$120.00 $
$144.00 $
Family..................................... $156.22
One-time administration fee (non-refundable)......... $ + 20.00
TOTAL $
AmEx
MasterCard
VISA
Credit Card#
Expiration Date:
Discover/NOVUS
Cash
Check or Money Order (Payable to Lee Dental)
Office Name or Number
City
Sex (Check One)
Male
Female
Home Phone
State
ZIP
Plan Use Only
(PLEASE PRINT CLEARLY)
$1320.00
$352.00
On behalf of the above named individuals, I hereby apply for
enrollment in DENTAL PASSPORT PLAN, and certify that the above
information is true and correct.
$490
Child
$4410
Child
$4900
$1200.00
$1360.00
Spouse
Orthodontics*
REMOVABLE PROSTHEDONTICS
COMPLETE DENTURE – PER ARCH
IMMEDIATE DENTURE – PER ARCH
REMOVABLE PARTIAL DENTURE –
METAL FRAME – PER ARCH
RELINE EXISTING DENTURE – PER ARCH
Birthdate
$110
Sex
$440
Name
$550
ELIGIBLE DEPENDENTS
In-office
whitening
Email Address
$118
Date of birth
$114
$548.00
$632.00
$756.00
Work Phone
$232
$119.00
$150.00
$189.00
$714.00
$668.00
$756.00
$756.00
Employer
Exam, x-rays, and
routine cleaning
ROOT CANAL THERAPY
ROOT CANAL – ONE ROOT
ROOT CANAL – TWO ROOTS
ROOT CANAL – THREE ROOTS
$108.00
$133.00
$161.00
Address
Usual Fee Plan Fee Savings
$0
$125
$125
RESTORATIVE CARE
TOOTH COLORED/RESIN FILLINGS (FRONT/ANTERIOR TEETH)
ONE SURFACE
TWO SURFACES
THREE SURFACES
TOOTH COLORED/RESIN FILLINGS (BACK/POSTERIOR TEETH)
ONE SURFACE
TWO SURFACES
THREE SURFACES
CROWN – PORCELAIN FUSED TO GOLD
CROWN- PORCELAIN FUSED TO METAL
CROWN – ALL PORCELAIN
VENEER (PER TOOTH)
Effective Date
Full mouth
digital x-rays
$137.00
$220.00
$137.00
$103.00
$40.00
First Name
Savings with Dental Passport Plan
PERIODONTAL CARE
PERIODONTAL SCALING AND ROOT PLANING 1-3 TEETH/QUADRANT
PERIODONTAL SCALING AND ROOT PLANING 4+ TEETH/QUADRANT
FULL MOUTH DEBRIDEMENT
PERIODONTAL MAINTENANCE CLEANING
SUBGINGIVAL IRRIGATION (PER QUADRANT)
Last Name
• No claim forms
• No deductibles
• No “waiting period for dental treatment”
• No limitations on most conditions
• No shortage of locations
$51.00
$28.00
$42.00
NO CHARGE
NO CHARGE
NO CHARGE
$59.00
$49.00
$27.00
$35.00
Plan Use Only
Your journey to
Dental Health simplified!
DIAGNOSTIC AND PREVENTATIVE CARE
COMPREHENSIVE EXAM (NEW OR EXISTING PATIENT)
PERIODIC/RECALL EXAM
LIMITED ORAL EXAM (PROBLEM FOCUSED)
BW DIGITAL X-RAYS
PERIAPICAL DIGITAL X-RAYS
PANORAMIC FILM
ROUTINE CLEANING (ADULT)
ROUTINE CLEANING (CHILD)
TOPICAL FLUORIDE APPLICATION
SEALANT (PER TOOTH)
Initial
List of Discount Services Under Lee Dental Passport Plan.