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)
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Individual
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Family Plan
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$6.00
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$10.00
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There is a one time enrollment fee of $20.00 which
will be drafted from your bank account.
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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
Bank Draft Information: (This Section MUST be Completed!)
How did you hear about us?
Dental Provider
Family/Friend
Search engine (Google, Yahoo, etc.)
Facebook
LinkedIn
Other
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
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