Terms and Conditions

I wish to enroll with American Dental Care Partners, Inc. I understand this is an annual agreement and that all necessary dental services will be provided as described in the Member Fee Schedule. I have received a copy of the Member Fee Schedule. This plan will automatically renew every year unless otherwise notified and payment on file will be applied. If paying for 6 months, filling out this application authorizes American Dental Care Partners, Inc. to automatically debit the member’s remaining 6 months of the one-year agreement from the account used to pay for the first 6 months. An annual service fee will apply, not to exceed $12.00. Returned checks will result in a $30 fee. A late fee will be assessed, not to exceed $4.00 for each month the membership is past due. If the member cancels membership with American Dental Care Partners, Inc. within the first 30 days after the effective date of enrollment in the plan, the member shall receive a reimbursement of all periodic charges upon return of the discount card to American Dental Care Partners, Inc. Cancellations by telephone will not be accepted. The cancellation must be in writing to:

American Dental Care Partners, Inc., 11221 Katy Freeway, Suite 209, Houston, TX 77079. Or fax 713-784-6928.

Note* American Dental Care Partners, Inc. does not share and sell your email or any personal information.

The annual service fee, the returned check fee and the late fee do not apply to FL residents.