What is a dental membership plan agreement?
Many dental practices offer uninsured patients an in-house membership plan: a monthly or annual fee covers routine check-ups, cleanings and X-rays, with a discount on other treatment. The plan agreement is what makes it work — it tells the patient exactly what they get, how they pay and how to leave, and it says clearly that the plan is not insurance.
This template opens with a bold not-insurance statement and a reminder that some places regulate in-house plans. It lists the covered people, the services included each plan year, an optional discount and exclusions, and the fee for all covered people, billed monthly or annually by card, bank debit or at the practice, with an optional joining fee. It covers automatic payment authorisation, failed payments, fee changes at renewal with notice, automatic renewal or re-enrolment, cancellation notice, a fair early-cancellation calculation for monthly plans, refunds for annual plans, the practice's right to end a membership, and appointments and records.
- Best for
- Dental practices running in-house membership or savings plans
- Signed by
- The practice (with job title) and the member who pays
- Billing
- Monthly or annual, for all covered family members
- Length
- About 2 pages
When to use a dental membership plan agreement
- A practice enrols an uninsured adult in its preventive care plan
- A family joins a plan covering two adults and two children
- A patient between jobs switches from insurance to the practice's plan
- A practice launches a membership plan and moves sign-ups online
- A member renews for another plan year at a new fee
What you fill in
21 blanks, then the name and email of each person who signs: practice, member.
1 The practice
- Dental practice*
- Practice address
- Practice phone
2 The plan
- Plan name*
- Plan start date*
- Included each plan year*
- Discount on other treatment (%)
- Treatment the discount does not apply to
3 The member
- Member (the person paying)*
- Member address
- Member email
- People covered by the plan*
4 Fees
- Currency*
- Billing* monthly · annually
- Plan fee per billing period (all covered people)*
- One-off joining fee
- Payment method* automatic card payment · automatic bank debit · payment at the practice
5 Renewal and cancellation
- Renewal* The plan renews automatically each plan year unless cancelled · The plan ends at the end of the plan year unless the Member re-enrols
- Monthly plans: minimum commitment* 12 months · none
- Notice to cancel (days)*
- Governing law*
6 Who signs
- Practice signature and date, job title · The dental practice offering the plan.
- Member signature and date · The adult who joins and pays for the plan, for themselves and any family members listed.
What the dental membership plan agreement covers
- This plan is not insurance
- Who is covered
- What is included
- Fees and payment
- Renewal and cancellation
- Appointments and records
- General
Using the dental membership plan agreement, step by step
1 Describe the plan
Enter the plan name, start date, the services included each plan year, and any discount on other treatment and what it excludes.
2 Add the member and family
Enter the paying member and list each covered person, all of whom must be patients of the practice.
3 Set fees and renewal
Choose monthly or annual billing, the fee, any joining fee and payment method, whether the plan renews automatically, the minimum commitment for monthly plans and the cancellation notice.
4 Send for signature
Add the member as a signer and send. The signed agreement is filed in your vault and emailed to both of you.
Tips before you send it
- Keep the not-insurance statement exactly as it is — it is the most important sentence in the agreement.
- Check whether in-house dental plans are regulated where you practise before launching one.
- Send a reminder before the end of each plan year, as the agreement promises.
- Track included services used, so early-cancellation and refund calculations are easy.
Sign it online in minutes
- Fill in the blanks. Names, dates and amounts go straight into the agreement — the preview shows exactly where.
- Name who signs. Tick “This is me” for your own part. FileIt builds the PDF with every signature, date box on the right line, and you can check or move anything before sending.
- Send it. Each signer gets a secure link and signs from any device — no account needed. The signed PDF, with an audit trail and a Certificate of Completion, is filed in your vault and emailed to everyone.
Dental membership plan agreement: frequently asked questions
Is a dental membership plan insurance?
No. It is an agreement between the patient and the practice only. It doesn't pay for care elsewhere, isn't a claim-paying arrangement, and can't be billed to an insurance plan for the same services.
What if a member cancels a monthly plan early?
If there is a minimum commitment, the member pays the lower of the remaining monthly fees or the amount, if any, by which the value of benefits already received (standard fees for included services used, plus discounts given) exceeds the plan fees paid. Nothing more is owed.
Can the practice change the fee?
Yes, from the next renewal, with at least 30 days' written notice.
Is a document signed electronically legally binding?
In most countries, including the US (ESIGN Act and UETA), the UK, the EU (eIDAS) and Canada, an electronic signature is generally valid for an ordinary agreement like this one. FileIt keeps an audit trail and a Certificate of Completion with the signed PDF as evidence of who signed and when.
Is this template free?
Yes. The template is free to use with the eSignature app in FileIt. The member doesn't need a FileIt account to sign.