Louisiana Dental Plan Bank Draft Application

Welcome to the Louisiana Dental Plan Bank Draft System.
Simply complete this form, agree to the terms of enrollment, and click the submit button.

Monthly Payment (Bank Draft Only)
Individual	Family Plan
$6.00	$10.00
There is a one time enrollment fee of $20.00 which will be drafted from your bank account.

Please complete all of the following information.

Date:

Name:

Address:

City: State: Zip:

Email Address:

Home Phone: Work Phone:

Employer:

Date of Birth:

Note: The following section should only be filled out if you desire coverage for dependents

Spouse/Children/Dependents	Sex	Date of Birth

Bank Draft Information: (This Section MUST be Completed!)

Name (As It Appears on Account)
Plan Type (Monthly Fee)
Account Number (Include any needed zeroes)
Routing Number - * REQUIRED (The first nine digits at the bottom of most checks)
Bank Name
Type of Account

How did you hear about us?

I AGREE to ALL Louisiana Dental Plan terms and conditions as listed below.

I hereby authorize Louisiana Dental Plan to draft my checking or saving account for the $20.00 enrollment fee and the monthly payment.

I hereby submit my application to enroll in the Louisiana Dental Plan. I hold the Louisiana Dental Plan blameless for negligence on the part of any participating provider. I accept liability for all payments due to Louisiana Dental Plan up to and until I cancel the plan. I understand that I must cancel my account at least 5 days prior to the date of my next drafting. I also understand that my account may be canceled by Louisiana Dental Plan at any time due to unavailability of funds or inaccessibility of my account. Please print out this form, after completion, for your records. Please contact us with any questions (Toll Free) at 1-800-256-1948.

**If you are unsure about any of the above information, please contact your bank before submitting.
***There is a $20.00 fee for all insufficient ACH bank drafts.

Limitations, Exclusions & Exceptions: This plan is a discount membership program offered by Louisiana Dental Plan. Louisiana Dental Plan is not an insurance, health maintenance organization or other underwriter of health care services. No portion of any provider's fees will be reimbursed or otherwise paid by Louisiana Dental Plan. You will receive discounts for services at certain dental care providers who have contracted with the plan. You are obligated to pay for all dental care services at the time of service. The range of discounts provided under the plan vary depending on the type of provider and the services received. The plan's discounts 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. Any procedures performed by a non-participating provider are not discounted. Providers are subject to change. It is the member's responsibility to verify that the provider participates in the plan. Louisiana Dental Plan cannot guarantee the continued participation of any provider. If the provider leaves the plan, you will need to select another provider. Providers contracted by Louisiana Dental Plan are solely responsible for the professional advice and treatment rendered to members and Louisiana Dental Plan disclaims any liability with respect to such matters.

For information, assistance, and an up-to-date list of providers participating in Louisiana Dental Plan, contact:
Customer Service
E-mail: response@louisianadentalplan.com
Toll-Free Phone: 800-256-1948