CM-2026-102 - 4/10/20261
Jet Dental Service Agreement
This Service Agreement (the "Agreement") is entered into as of _________________ (the "Effective Date"), by and between
Jet Management Services, LLC, dba Jet Dental, a Utah limited liability company with its principal place of business at
3451 N. Triumph Boulevard, Suite G50, Lehi, UT 84043 ("Jet Dental"), and _______________________, with a principal
address at ______________________________________________ ("Client"). Jet Dental and Client may be referred to
individually as a "Party" or collectively as the "Parties."
1. Scope of Services
1.1 Dental Services. Jet Dental agrees to provide on-site dental services (the "Services") at the location specified by
the Client on the date(s) listed on the signature page (the "Event Date"), as well as any additional date(s) mutually
agreed upon in writing by both Parties that may not be explicitly listed in this Agreement. The Services may include:
Routine dental care (e.g., dental prophylaxis, exams, x-rays, cavity fillings)
Teeth whitening.
Any additional Services mutually agreed upon as listed in the Additional Patient Services Paid for by Client.
1.2 Staffing and Equipment. Jet Dental will supply the necessary dental staff, including licensed dentists or
teledentists, and all required equipment to perform the Services. Jet Dental will also manage dental insurance
verification and billing, provided Client submits necessary information in advance of the Event Date.
1.3 Service Availability. The Services offered may vary by location due to local statutes or regulations. Jet Dental will
provide a list of Services available at a specific Event upon request.
1.4 Promotional Materials. Jet Dental will provide promotional materials ("Promotional Materials") in physical or
-up procedures.
1.5 Business Associate Agreement (BAA). To ensure compliance with HIPAA regulations and facilitate the secure
handling of protected health information (PHI), the Parties may agree to execute a separate Business Associate
Agreement (BAA), which shall be incorporated by reference into this Agreement upon execution. While Jet Dental will
not share any health-related data, the signed BAA will enable Jet Dental to share appointment times with the Client.
2. Client Responsibilities
2.1 Site and Event Confirmation. By executing this Agreement, Client confirms the Event Date. Client is
responsible for selecting, photographing, and providing dimensions of the proposed Event site, which is subject to
Jet Dental's approval.
2.2 Benefits Request. Client agrees to provide Jet Dental with all necessary benefits and insurance information
(e.g., a sample insurance card) to enable Jet Dental to complete insurance verification and billing. Jet Dental shall
2.3 Event Promotion and Communication. Client is responsible for sharing Promotional Materials to help
Client chooses, Jet Dental can also hel
and/or text. These communications will only be used to promote the event and will take place within the 4 to 6
or approval. In return for allowing Jet Dental to
assist with employee outreach, Jet Dental agrees to waive the minimum Event fees.
City of Round Rock
221 E Main St. Round Rock TX 78664
CM-2026-102
2
2.4 Additional Patient Services-optional. If Client elects to pay for services beyond the basic Services listed
above, such services will be subject to separate terms and pricing. The authorization form titled "Additional Patient
Services Paid for by Client" must be completed to activate this option.
2.5 Vendor Forms. If Client requires vendor registration or documentation (e.g., Risk Management Questionnaire,
Vendor Registration), such forms must be submitted to Jet Dental at least 30 days before the Event Date.
2.6 Insurance Request. Upon Client nformation or
documentation.
3. Fees, Payment, and Cancellation
3.1 Minimum Appointments. A minimum of fifteen (15) appointments must be completed for the Event to be
cost-free. If fewer than fifteen (15) appointments are completed, Client shall pay $300 for each appointment under
the minimum. Charges are based on completed appointments, not scheduled appointments.
3.2 Cancellation. Client may cancel without penalty if notice is given at least sixty (60) days before the Event Date.
Cancellations made within sixty (60) days of the Event Date are subject to a cancellation fee of $2,500 per scheduled
Event Date.
3.3 Invoicing and Payment. All applicable fees will be invoiced, and payment is due within thirty (30) days (Net
30). If Client opts to use credit card payments, an "Optional Credit Card Authorization Form" must be completed,
authorizing Jet Dental to charge the provided card for any invoiced amounts.
4. Term and Termination
4.1 Term. This Agreement shall commence on the Effective Date and remain in effect through the Event Date, and
thereafter until canceled by either Party upon written notice, unless earlier terminated as provided herein.
4.2 Termination for Cause. Either Party may terminate this Agreement upon written notice if the other Party
materially breaches any provision and fails to cure such breach within fifteen (15) days of receiving written notice.
5. Confidentiality. Each Party agrees to maintain the confidentiality of all non-public, proprietary information disclosed in
connection with this Agreement and not to use or disclose such information except as necessary to perform its obligations
hereunder.
6. Limitation of Liability. EXCEPT FOR CLAIMS ARISING FROM GROSS NEGLIGENCE OR WILLFUL
MISCONDUCT, NEITHER PARTY SHALL BE LIABLE TO THE OTHER FOR ANY INDIRECT, INCIDENTAL,
SPECIAL, CONSEQUENTIAL, OR PUNITIVE DAMAGES.
7. Indemnification. Each Party (the "Indemnifying Party") agrees to indemnify, defend, and hold harmless the other Party,
its affiliates, officers, and employees (the "Indemnified Party") from any third-party claims, damages, or liabilities arising
8. Force Majeure. Neither Party shall be liable for failure or delay in performance caused by events beyond its reasonable
control, including but not limited to acts of God, natural disasters, strikes, war, or governmental regulations (a "Force
Majeure Event").
9. Miscellaneous. This Agreement, together with any attachments and the BAA, constitutes the entire agreement and
supersedes all prior agreements or communications, whether written or oral. Any amendment must be in writing and signed
by both Parties. If any provision is found to be unenforceable, it shall be modified to the extent necessary to be enforceable,
and the remainder of the Agreement shall remain in full force. This Agreement shall be governed by and construed in
accordance with the laws of the State of Delaware, without regard to its conflict of laws provisions. All notices must be in
writing and delivered via email, personal delivery, or certified mail to the addresses specified by each Party. The prevailing
3
IN WITNESS WHEREOF, Jet Management Services, LLC and Client have each caused this Services Agreement to be
duly executed in its name and on its behalf, effective as of the Effective Date.
JET MANAGEMENT SERVICES, LLC dba
JET DENTAL
Signature:_______________________________
Name: _________________________________
Title:___________________________________
Date:___________________________________
C
Signature:________________________________
Name: ___________________________________
Title:_____________________________________
Date:_____________________________________
4
Client Set-Up Information
PRIMARY CONTACT
Name
Email
Phone Number
BILLING CONTACT (Separate from Primary Contact)
Name
Email
Phone Number
REMIT TO ADDRESS
Client Full Legal Name
Address 1
Address 2
City
State
Zip Code
PAYMENT TERMS
Terms of Payment Net 30
Check if you authorize an auto-draft of your credit card to pay for
outstanding invoices. If you check this box, please complete the
Optional Credit Card Authorization Form.
Sang Dhar
sdhar@roundrocktexas.gov
737-226-6960
City of Round Rock / Accounts Payable
512-218-5440
apinvoices@roundrocktexas.gov
City of Round Rock
221 E Main St
Round Rock
Texas
78664
5
Optional Credit Card Authorization Form
The undersigned hereby authorizes Jet Dental to charge the credit card below for the amount owed to Jet Management
Jet Dental
authorization will remain in effect until the undersigned notifies Jet Dental in writing, pursuant to the terms of the Jet Dental
Service Agreement, that such authorization has been revoked.
CREDIT CARD INFORMATION
Name on Card
Card Number
Expiration Date
CVV Code
Billing Address 1
Billing Address 2
City
State
Zip Code
Client Name: _______________________________
Name of Client Company
Signature: _______________________________
Name: _______________________________
Title: _______________________________
Date: _______________________________
6
Optional Additional Patient Services Paid For By Client
Purpose of Authorization. This form authorizes additional services to be provided on the Event Date that will
be paid for by the Client. Jet Dental will issue a separate invoice for these services. By signing this form, the
Client acknowledges their responsibility for any outstanding balances and agrees to pay such amounts as outlined
below and invoiced by Jet Dental.
Check the box to the left of each item below to authorize payment of additional patient services:
Payment Terms. All balances are due upon receipt of the invoice.
Acknowledgment and Signature. I understand that I am responsible for payment of any outstanding balances
resulting from services provided by Jet Dental. I agree to the terms outlined in this authorization and confirm that
the information provided above is accurate.
Client Name: _______________________________
Signature:
Name:
Title:
Date:
_______________________________
_______________________________
_______________________________
_______________________________
Uninsured or cash-pay patients.For patients who are uninsured or choose to pay out-of-pocket,
balances will start at $150. Final amounts may vary based on treatment needs. A detailed invoice
will be provided for all services rendered
Teeth whitening treatments
Co-pays and deductibles not covered by insurance
Other (please specify)
7
HIPAA BUSINESS ASSOCIATE AGREEMENT
overed Entity each referred to herein as a
WHEREAS, Business Associate has an arrangement to provide services on behalf of one or more organizations identified
as a Covered Entity under 45 C.F.R. § 160.103; and
W
WHEREAS, in the course of providing the Services, Covered Entity may make available to Business Associate, or have
Business Associate obtain on its behalf, information that may be deemed Protected Health Information (PHI) subject to the
provisions of HIPAA.
NOW THEREFORE, in consideration of the mutual promises set forth in this BAA, and other good and valuable
consideration, the sufficiency and receipt of which is hereby acknowledged, the Parties agree as follows:
1. Definitions. Capitalized terms used but not otherwise defined in this BAA shall have the meanings ascribed in
HIPAA (whether or not such terms are capitalized therein) or elsewhere in the Primary Agreement.
protected health information as required by 45 C.F.R. § 164.404.
by Business Associate for or on behalf of Covered Entity.
meaning given in 45 C.F.R. § 164.402.
2. Permitted Uses. Business Associate may use PHI only as permitted or required by this BAA for the following
purposes: (i) as necessary to provide the Services; (ii) to carry out its legal responsibilities; (iii) for the proper
business management and administration of Business Associate; (iv) to provide data aggregation services relating
to the health care operations of Covered Entity to the extent necessary or requested to provide the Services; and (v)
as required by law.
3. Permitted Disclosures. Business Associate may disclose PHI only as permitted or required by this BAA. Disclosure
may include, but is not limited to, patient names and appointment dates/times, and such other information as
necessary for treatment, payment, and healthcare operations (TPO) as allowed under HIPAA. Any disclosure to an
agent or subcontractor of Business Associate shall be made pursuant to a written agreement containing substantially
the same restrictions and conditions as set forth in this BAA. If additional PHI is requested by the Covered Entity,
and if required under HIPAA, it is the responsibility of the Covered Entity to obtain proper authorization from the
patient.
4. Prohibited Uses and Disclosures. Business Associate shall not use or further disclose PHI in a manner that would
violate HIPAA if done by the Covered Entity. Business Associate shall not sell PHI or use/disclose PHI for
marketing or fundraising without proper authorization as set forth in Section 13405(d) of the HITECH Act.
5. Safeguards. Business Associate shall establish and maintain appropriate administrative, physical, and technical
safeguards in compliance with HIPAA and HITECH (including Section 13401), to protect the confidentiality,
integrity, and availability of Electronic PHI.
6. Reports to Covered Entity; Breach Notification. Business Associate shall report any Breach of Unsecured PHI to
Covered Entity in writing, without unreasonable delay and no later than ten (10) calendar days after discovery, in
accordance with 45 C.F.R. § 164.404 and Section 13402 of HITECH. Business Associate shall report other
unauthorized uses or disclosures of PHI within thirty (30) days of discovery. Business Associate shall report
City of Round Rock
8
Security Incidents involving Electronic PHI within thirty (30) days, excluding routine network security events such
as pings or failed login attempts.
7. Reimbursement; Mitigation. Business Associate shall reimburse Covered Entity for reasonable and necessary out-
of-pocket costs related to required breach notifications and shall cooperate in mitigating any harmful effects.
8. Minimum Necessary. Business Associate shall use or disclose only the minimum PHI necessary to accomplish the
intended purpose of the use or disclosure, in accordance with 45 C.F.R. § 164.502(b).
9. Access
for access to or amendment of PHI. Business Associate shall direct Individuals to Covered Entity unless otherwise
directed. For PHI in a Designated Record Set, Business Associate shall provide access to Covered Entity or a third-
party designee, and amend PHI as requested by Covered Entity, in accordance with 45 C.F.R. § 164.524 and Section
10. Accounting for Disclosures. Business Associate shall document and retain records of disclosures of PHI as required
under HIPAA and shall provide such documentation to Covered Entity or the Individual upon request.
11. Additional Restrictions. Business Associate shall comply with any additional restrictions on PHI use or disclosure
notified by Covered Entity in accordance with 45 C.F.R. § 164.522(a).
12. Audit. Upon request by the Secretary of HHS, Business Associate shall make internal records related to PHI
available for compliance review. Business Associate shall notify Covered Entity of such requests unless prohibited
by law.
13. Remuneration. Business Associate shall not receive remuneration for PHI except as authorized under HIPAA and
HITECH.
14. Obligations of Covered Entity. Covered Entity shall provide necessary notices, consents, and authorizations, and
notify Business Associate of limitations, restrictions, or changes affecting PHI disclosures.
15. Termination. This BAA shall terminate upon the expiration/termination of the Primary Agreement or upon material
breach uncured within thirty (30) days of notice. Upon termination, Business Associate shall return or destroy all
PHI, if feasible, or continue to protect PHI and limit its use/disclosure if return or destruction is infeasible.
16. Miscellaneous. Amendments. This BAA may be amended in response to changes in applicable law or regulations.
Covered Entity may propose amendments in writing; if rejected by Business Associate and not resolved within
thirty (30) days, either Party may terminate the BAA. Interpretation. In case of conflict, the terms of this BAA shall
prevail over the Primary Agreement. Mandatory provisions of HIPAA and HITECH shall supersede any conflicting
terms.
Signatures on the following page
9
IN WITNESS WHEREOF, Business Associate and Covered Entity have each caused this Business Associate
Agreement to be duly executed in its name and on its behalf, effective as of the Effective Date.
JET MANAGEMENT SERVICES, LLC dba
JET DENTAL
Signature:_______________________________
Name: __________________________________
Title:___________________________________
Date:___________________________________
Signature:________________________________
Name: ___________________________________
Title:_____________________________________
Date:_____________________________________