Vermont Dental Care
 
 
 
CALL
 
32 Malletts Bay Ave Ste B, Winooski, VT 05404
 
 
185 N Main St ste 10, Barre, VT 05641
 
 
 
 
 
 
 

Patient Forms



Patient Insurance Information

 
 
 
 
 
 
1st Ins Coverage
 
 
 
 
 
 
2nd Ins Coverage
 
 
 
 
 
 
Dependents on ins. policy or policies
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Patient Consent Form

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.
 
Date:
 
 
 
 
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.

  1. 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."
  2. 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."
  3. 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.
  4. 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.
  5. 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.

Date:

Vermont Dental Care Programs

Payment Selection

 
 
 
 
 
 
 
 
I, hereby choose one of the following methods of payment for my dental treatment at Vermont Dental Care. Please check your selection.

I have Dental Ins. with I understand that I must pay my deductible and any estimated balance due on the date of service.

I have Dental Ins. I understand that payment is due in full on the date of service. Vermont Dental Care accepts cash, check, VISA, Mastercard, Discover, and Care Credit. We do not accept American Express.

I am a senior citizen (over 60) Reduced fee is available for patients over age 60 who do not have dental insurance. Payments is due in full on the date of service.

Reduced Fee Vermont Dental Care offers a reduced fee schedule for those patients who are income or age eligible. A federal or state tax return is needed for proof of income and must be furnished each year, for renewal of reduced fee. Payment is due in full on day of service.

Person Financially Responsible (please print)

Date
 
 

Vermont Dental Care

Medical history

 
 
Birth Date:
 
Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.
 
 
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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.