Medicaid Insurance Form

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We are pleased that you have chosen our practice for your child’s dental care. To make our time together most efficient and enjoyable, we have listed several guidelines. Please read them carefully.

  1. Be on time for all appointment. Failure to do so may make it necessary to reschedule the appointment.
  2. Bring your current Medicaid card. We cannot treat your child without a current card.
  3. Exam are covered once per 6 months – If you are seen off your recare frequency, you will be responsible to pay for the exam on the day of service.
  4. Inform us of changes in eligibility. You will be billed if your child is not eligible.
  5. Co-payments. Not all services are covered by Medicaid and some co-payments may be necessary. If a co-payment is necessary, you will be notified in advice.
  6. Missed appointments. If you fail to keep any scheduled appointment without prior notice, you will be notified by mail that we will no longer see your child/children for routine dental care. We will provide emergency treatment for 30 days following the missed appointment to allow you to find another dentist who accepts Medicaid.’
  7. Broken fillings/space maintainers. Help your children take care of the dental work we provide! Replacement of broken fillings and lost/broken space maintainers are not always covered by Medicaid. You will be responsible to pay for replacement of any dental work that we determine is not covered by Medicaid.

These policies are for the benefit of everyone. If you have questions please call our office to speak with the practice administrator.

Thank you.