Welcome to the Louisiana Dental Plan Credit Card Payment System.
Simply complete this form, agree to the terms of enrollment, and click
the "Pay with Card" button.
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Monthly Payment
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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:
Plan Type (Monthly Fee):
Note: The following section should only be filled out if you desire coverage for dependents
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 charge my card for the
$20.00 enrollment fee and the monthly payment. Recurring payments
will be processed until cancellation notice is provided.
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 payment. 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 credit card payments.
LOUISIANA DENTAL PLAN ("LDP") IS A DISCOUNT PLAN AND IS NOT INSURANCE COVERAGE. MEMBERS RECEIVE DISCOUNTED PRICING
ON DENTAL SERVICES FROM PARTICIPATING PROVIDERS. THE RANGE OF DISCOUNTS PROVIDED UNDER THE PLAN VARY DEPENDING ON
THE TYPE OF PROVIDER AND THE SERVICES RECEIVED. MEMBERS ARE OBLIGATED TO PAY FOR ALL SERVICES PROVIDED BY A LDP
PROVIDER, BUT MEMBERS WILL RECEIVE A DISCOUNT FROM THOSE PROVIDERS THAT HAVE CONTRACTED WITH LDP.
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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