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Application Form

To join by mail, simply fill out the following application form, print it, and mail along with check or money order, or credit card information to:

Ardent Dental
50 East 91st Street, Suite 205
Indianapolis, Indiana 46240
Phone: (317) 818-9700
Fax: 317-818-9701

To submit this form using e-mail (for online application) , fill out the following form and click submit when finished.

Ardent Dental Savings Program Application Form:

Members Name:
      
Last:
   
First:
    
Middle:
    
Home Address:
   
City:
    
State/Zip:
 /    
Home Phone:
   
Date of Birth:
 / /    
Sex:
    
Email Address:
   
     
Do you wish to add eligible dependents?:
    
Name of Dependent:
Date of Birth
 / /
Name of Dependent:
Date of Birth
 / /
Name of Dependent:
Date of Birth
 / /
Name of Dependent:
Date of Birth
 / /
Name of Dependent:
Date of Birth
 / /

Credit Card #

Expiration Date:

Please choose payment:   Visa   Mastercard  

I hereby request services for me and my entire family listed on this application. I understand that the discounts available through this program are only available at participating DNoA Select providers. Upon making an appointment for dental care, I understand that I need to identify myself as a Ardent Dental Savings Program / DNoA Select member. Upon seeking care, I need to present my Ardent Dental Savings Program / DNoA Select identification card. I understand that discounts offered by this program are only available if my membership fee is current. I hereby represent to you that all information furnished by me herein is true and complete to the best of my knowledge, and shall be deemed representations upon which all rights under this program are conditioned.


(For e-mail submission)

 

Signature X_____________________________________\_____________

(only required if submitting enrollment form by mail.)

If submitting application by mail, print the form, complete the form and mail it to:

Ardent Dental
50 East 91st Street, Suite 205
Indianapolis, Indiana 46240

Thank you!


THIS PLAN IS NOT INSURANCE. THIS IS NOT A MEDICARE PRESCRIPTION DRUG PLAN.*
The plan provides discounts at certain health care providers for medical services. The range of discounts will vary depending on the type of provider and service. The plan does not make payments directly to the providers of medical services. Plan members are obligated to pay for all health care services but will receive a discount from those health care providers who have contracted with the discount medical plan organization. Before purchase, you may access a list of participating health care providers at this website. Upon request the plan will make available a written list of participating health care providers. You have the right to cancel within the first 30 days after receipt of membership materials and receive a full refund, less a nominal processing fee (nominal fee for MD residents is $5). Discount Medical Plan Organization and administrator: Careington International Corporation, 7400 Gaylord Parkway, Frisco, TX 75034; phone 800-441-0380.

Note to Texas Consumers: Regulated by the Texas Department of Licensing and Regulation, P.O. Box 12157, Austin, Texas 78711; telephone 1-800-803-9202 or (512)463-6599 website: www.license.state.tx.us/complaints. The program and its administrators have no liability for providing or guaranteeing service by providers or the quality of service rendered by providers. *Medicare statement applies to MD residents when pharmacy discounts are part of program. This program is not available in Florida, Montana, Vermont, Nevada, California and South Dakota.
 
LIABILITY: assumes no liability with regard to any services provided, or to be provided, by any participating vendor. You agree that any claim with regard to services shall be made against the vendor of such services and not Ardent Dental. Ardent Dental sole obligation hereunder shall be to present vendor products services and/or offers to you. Vendor is defined as any company with whom we, or our agent contract with to provide you discounts or other special offers. Ardent Dental is not a licensed insurer, health maintenance organization, or other underwriter of healthcare services. Ardent Dental is not licensed to provide and does not provide medical or health services or terms to individuals. Providers or vendor s are solely responsible for the professional advice and treatment rendered to members and Ardent Dental disclaims any liability with respect to such matters.
DISCOUNTS AND SAVINGS: This program is not insurance. It is a discount membership program offered by Ardent Dental. Ardent Dental is not meant to replace your existing health insurance. We will contract with vendor to provide you with such discounts. Member’s enrollment in Ardent Dental must be active at the time the discount is requested. Savings are based upon the provider’s usual and customary fees. Actual savings will vary depending upon location and specific services or products purchased. The discounts contained herein may not be used in conjunction with any other discount plan or program. All listed or quoted prices are current prices by participating providers and subject to change without notice. Providers may offer products or services to the general public at prices lower than the discounted prices available through this program. In such event, members will be charged the lowest price.
liability