1000 Eleven South Suite 3F, Columbia, IL 62236, US
SmileSavers In-Office Discount Plan
Designed for patients without dental insurance or those who prefer a better plan.
The SmileSavers Dental Discount Plan is offered exclusively by Synergy Dental Solutions and available only at 1000 Eleven South Suite 3F Columbia, Illinois. Dr. Angela Tenholder is a licensed dentist through the State of Illinois, has Fellowship Status in the Academy of Craniofacial Pain and is a Diplomate of the American Board of Craniofacial Dental Sleep Medicine. If there is a change in Dr. Tenholder’s licensure and certification status, you will be notified immediately.
• No deductibles
• No claim forms
• No pre-authorization requirements
• No pre-existing condition limitations
• No waiting periods for eligibility
• No yearly maximum
• No benefits given for procedures that are provided by dental specialists outside of our office. (In the event Dr. Tenholder feels that it is in your best interest to receive care from another provider.)
• No benefits are available if used in conjunction with a workman’s compensation, automobile insurance claim or hospitalization.
Yearly Fees
• Individual Coverage $300
• Dual Coverage* $500
• Family Coverage (3 members)** $700
• Family Coverage (4 members)** $900
If you have more than 4 members in your family, there will be an additional $175 to the cost of the coverage. Example, if you have 5 members in your family, the cost of your coverage will be $900+ $175 = $1075.
* The dual plan is for legally married couples or parent/child
** The family plan includes dependent children up to age 26
**YOU MAY NOT HAVE THIS PLAN IF YOU HAVE DENTAL COVERAGE THROUGH AN INSURANCE PLAN***
Coverage Table
$5 co-pay for 2 annual cleaning and check-ups (a $548value).
• Child and Adult Prophylaxis (cleaning): **in a healthy mouth with gum pockets less than 4 mm
• Protective varnish (MI or Fluoride)
• Advanced oral cancer screenings
100% coverage on the following:
• Comprehensive Exam for New Patients
• Periodic Exams (checkup): 2 per year
• Limited Exam (emergency): 1 yearly
• Complete series of x-rays: 1 every 3 years
• Bitewing x-rays (checkup) : 1 yearly
• All intraoral x-rays (periapical view of the entire tooth and root)
50% coverage on the following:
• Sealants
• Space maintainers
• Periodontal maintenance appointments
35% coverage on the following:
• Periodontal services (full mouth debridement, scaling and root planning/deep cleaning in the presence of gum disease)
25% coverage on the following procedures and products:
• Fillings
• Crowns, bridges and implant abutments
25% coverage on the following procedures and products (continued):
• Dentures and partials
• Denture relines and repairs
• Oral surgery
• Root canals
• Implants
• Limited focus (emergency exams) if more than 1 per year is needed
• After hours emergency fees (in the event that we need to open the office for your emergency or call in prescriptions to your pharmacy while the office is closed)
• Night Guards (in the absence of obstructive sleep apnea, snoring, headaches or migraines)
• Advanced 3D imaging with our Cone Beam CT
Other coverage on the following:
• $500 discount on Orthodontics (excluding ALF Orthodontics Therapy)
Renewal of this agreement
You will be contacted within 30 days of the renewal/expiration date on this contract. If you agree to continue coverage, your yearly premium will be due prior to the renewal date. There will be a $50 penalty for late payment of the renewal premium. After the agreement has been executed and yearly deductible paid will this agreement will continue to be in effect. Refunds will not be made for this policy if any service has been rendered.
Termination of this agreement
Termination of this contract will have no less than 30 days prior written notice by either party who wishes to terminate the contract without cause. The rights and responsibilities under the contract cannot be sold, leased, assigned, assumed or otherwise delegated by either party without the prior written consent of the other party. Since Dr. Tenholder is the only health care provider; there will be no transfer of plan administration. The assignee must comply with all the terms and conditions of the contract being assigned, including all appendices, policies and fee schedules.
Dr. Tenholder will maintain adequate professional liability and malpractice coverage, through insurance, self-funding, or other means satisfactory to the administrator. Synergy Dental Solutions must be notified within no less than ten days after Dr. Tenholder’s receipt of notice of any reduction or cancellation of such coverage.
Dr. Tenholder will provide health care services without discrimination against any beneficiary on the basis of participation in the preferred provider program, source of payment, age, sex, ethnicity, religion, sexual preference, health status or disability.