Dental Savings Plan

We are accepting new patients
  
The Dental Savings Plan is designed to provide affordability and greater access to quality dental care.

If you have recently lost your dental coverage, or have never had dental coverage. This plan may be the right choice for you.

Your benefits are available only at H. Charles Jelinek, Jr., D.D.S.

 With your Dental Savings Plan there are: 

  • No yearly maximums

  • No deductables

  • No claim forms

  • No pre-authorization requirements

  • No pre-existing condition limitation

  • Immediate eligibility (no waiting periods)

  • Free Consultations

Benefit                   Premiums (Total Annual Cost)
Single                    $234.00

Dual*                     $457.00 

Family (3)**           $699.00           

Family (4)              $881.00 + $122 each additional member

PerioSavingsPlan $199 Additional per member ***

 *The Dual Plan is for Parent/ Child or Husband/ Wife only.
**The Family Plan includes children who are enrolled full-time in college until age 23, or children who are not enrolled full-time in college until age 18.
***Add to the benefit plans total annual cost an additional $199 per member. Receive all the benefits of the Dental Assistance Savings Plan  PLUS  Perio Prophylaxis(100% discount) 4 per year AND Scaling and Root Planning (20% discount) AND Fluoride (100% discount) 4 per year


You will not receive a membership card.

Your plans effective date will be on file with the office.

Auto renewal policy- 5% off. Sign up for auto renewal of your discount plan and receive 5 % off next year's premium! Ask our front desk team members how to sign up for this great offer!


Coverage Table

PREVENTIVE DENTAL CARE
 
Comprehensive Exam (new patient, initial visit)
100%
Periodic Exam (2 per year)
100%
Limited Oral Exam, Problem Focused (1 per year)
100%
Intraoral - Complete Full Mouth Series
100%
Intraoral - Periapical, First Film
100%
Intraoral - Periapical, Each Additional Film
100%
Bitewings (1 set per year)
100%
Child Prophylaxis (cleaning) 2 per year
100%
Adult Prophylaxis (cleaning) 2 per year
100%
Additional Cleanings per year
20%
Fluoride. 2 per year, no age limit
100%
Oral Cancer Screening
No Charge
Sealants
50%
RESTORATIVE SERVICES
 
Fillings - Tooth Colored Composites - and Core build ups
20%
Veneers
20%
Crowns and Bridges ***
20%
Dentures and Partials***
20%
Inlays , Onlays
25%
Implants (Restorative)***
15%
OTHER SERVICES
 
Bleaching / Whitening
$325
Orthodontics*- Invisalign or Six Month Smiles
$500.00 off
Periodontal Cleanings - Scaling and Root Planning non surgical gum disease treatment
20%
Extractions , Oral Surgery
15%
Night Guards, Splints, Deprogrammers
20%
*** Senior citizen discount, additional 5% on selected items.  *For Orthodontics: Members must remain a plan member for the duration of treatment to retain discount plan benefits


Program Exclusions and Limitations

This program is a discount plan, not a dental insurance plan, and is secondary to any other dental plan. It cannot be used:

  • In conjunction with another dental plan.

  • For services for injuries covered under workman's compensation.

  • For treatment which, in sole opinion of the treating dentist or doctor, lies outside the realm of their capability.

  • For referrals to specialists.

  • For hospitalization or hospital charges of any kind.

  • For costs of dental care which is covered under automobile medical.

  • In combination with any other offers or special discounts.


This Dental Savings Plan is only honored at H. Charles Jelinek, Jr., D.D.S. Dentistry.

This Dental Savings Plan is not an insurance plan that can be used at any other office.



Program Guidelines

  • Any service not paid in full at time of service will be billed at the usual and customary rate.

  • Canot be combined with ant special offers.

  • Plan is valid for one year from date of sign up.

  • Program cannot be used inconjunction with another dental plan.

  • NON-REFUNDABLE.

  • No refunds or premiums will be issued at any time if participant decides not to utilize the dental dental plan.

  • There will be a $50.00 reinstatement fee if your plan lapses.




 How To Enroll

To take advantage of the Dental Assistance Saving Plan, simply complete the following
steps:

 Please complete the form or Call Dental Assistance Plan Coordinator at 703-560-8700.

Complete the form, along with your payment or credit card authorization, and
mail it to 8505 Arlington Blvd, Ste 260, Fairfax, VA 22031. Please make checks payable to Dr H. Charles Jelinek Jr., D.D.S.


Enrollment Form