CHILD DENTAL BENEFITS SCHEDULE BULK BILLING PATIENT CONSENT FORM

I, the patient/legal guardian, certify that I have been informed:

of the treatment that has been or will be provided from this date under the Child Dental Benefits Schedule;
of the likely cost of this treatment; and
that I will be bulk billed for services under the Child Dental Benefits Schedule and I will not pay out-of-pocket costs for these services, subject to sufficient funds being available under the benefit cap.

I understand that I / the patient will only have access to dental benefits of up to the benefit cap.

I understand that benefits for some services may have restrictions and that Child Dental Benefits Schedule covers a limited range of services. I understand I will need to personally meet the costs of any services not covered by the Child Dental Benefits Schedule.

I understand that the cost of services will reduce the available benefit cap and that I will need to personally meet the costs of any additional services once benefits are exhausted.

Patient’s Medicare Number

Full Name

Balance Remaining

Patient/Legal Guardian Signature

Full name of person signing (if not the patient)

Date