Treatment Plan Financial Worksheet
Patient name:
This treatment plan is for:
Total case fee (UCR fees):
$
Select insurance type:
Enter fee after Advantage Plan discount:
$
Patient Total:$0
You are saving an estimated $0. That's 0% off our regular fees.
Enter estimated insurance payment:
$
Patient Total:$0
You are saving an estimated $0 with your insurance.
Enter in-network insurance discount:
$
Enter estimated insurance payment:
$
Patient Total:$0
You are saving an estimated $0. That's 0% off our regular fees.
Enter percent discount if paid in full prior to treatment (%):
%
Patient Total:$0
By prepaying your treatment, you are saving $0.
REGARDING INSURANCE: This is an estimate only. I acknowledge that this estimate does not guarantee payment. I understand that insurance plans may exclude certain procedures and have frequency limitations. I accept full financial responsibility for all services rendered and agree to pay any balance not covered by my insurance.
INITIALS:
I understand and agree to the above regarding insurance.
CONSENT: My signature below indicates that I understand the proposed treatment plan and costs. I've had the opportunity to ask questions regarding the risks, benefits, and alternatives to this treatment.
SIGNATURE:
Poway Modern Dentistry
Office of Dr. Viet Q. Nguyen
12630 Monte Vista Rd., Suite 109 • Poway, CA 92064
(858) 675-2285 • www.powaymoderndentistry.com