DDS GP In App Plan Worksheet

Patient name

This treatment plan is for:

Total case fee (UCR fees, $)

Dental insurance?

Enter fee after insurance/plan discount ($)

Enter estimated insurance payment ($)*

(always hidden) In network $ savings

(always hidden) In network % savings

Patient Total:

You are saving an estimated ${alwaysHidden122}! That's a {alwaysHidden}% discount!

Patient Total after estimated insurance payment*:

NoYes

Percent discount if paid in full prior to treatment (%):

(always hidden)...your savings by prepaying your treatment:

You are saving {yourSavings35} by prepaying your treatment!

Patient Total:

NoYes

CONSENT: My signature below indicate that I understand and agree with the proposed plan, including all treatment details, potential risks, benefits, costs, alternatives, and the steps involved.

REGARDING INSURANCE: I am aware that THIS IS AN ESTIMATE ONLY, and my insurance coverage may be affected if my eligibility has terminated, deductible has not been met, annual maximum has been met, or coverage differs from information the dental office was provided by me or my insurance company. I am aware that my potential full responsibility is listed above as Total Case Fee.

CONSENT: My signature below indicate that I understand and agree with the proposed plan, including all treatment details, potential risks, benefits, costs, alternatives, and the steps involved.