I give consent to Vermont Dental Care to disclose my personal health information for the purpose of carrying out treatment, payment, and or health care operations.
All health and dental information will be kept strictly confidential at Vermont Dental Care, Billing is done electronically or by US mail.
The following is a list of our current payment schedules. VDC requires that all patients, regardless of insurance coverage, pay their co-payment or estimated portion on the date of service.
Self pay patients: patients who pay for their treatment on the day of service, and have no insurance coverage. These fees are "regular full fee."
Insurance Patients: patients who have regular dental insurance (not state Medicaid.) The VDC computer estimates the insurance portion. Patients need to pay their estimated balance on the day of service. VDC bills the insurance company, adjusts patient statements if needed, and provided full accounting statements. These fees are also the "regular full fee."
Reduced Fee Patients: Patients who provide proof of limited income, and citizens age 60+. Proof must be in the form of previous years tax return, including W-2 forms. This must be renewed yearly. Payment must be made in full of the day of service, in order to receive the reduced fee. These fees are the "reduced fee" category.
Vermont Medicaid Adult (age 21+): For current patients with adult Medicaid, there is a required $3.00 co-payment, and a limited of $495.00 per year to use. Co-payments are due on date of service.
Vermont Medicaid Children (under age 21): Children under age 21 receive full coverage for all procedures and have no required co-payment, or financial limit.
VDC realize that some patients may not have the financial resources to pay for major procedures on the first day of treatment. If you feel you are unable to make payment in full, you need to contact our billing officer before treatment has begun.
VDC is dedicated to providing the best care for the most reasonable prices to all our patients. In order to continue doing this we must ask that all our patients meet their schedules above, or to meet with our billing office at 655-822.
I have read the above and had the opportunity to ask questions.
Vermont Dental Care Programs
Vermont Dental Care
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.