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Estimated Dental Procedure Minutes	Total Prepaid Fee	Deposit due at scheduling	Balance due prior to procedure
5	$450	$250	$200
10	$525	$250	$275
20	$650	$250	$400
40	$850	$250	$600
60	$1050	$250	$800
80	$1350	$250	$1100
100	$1550	$250	$1300
120	$1800	$250	$1550
140	$2100	$250	$1850
160	$2350	$250	$2100
180	$2600	$250	$2350
200	$2900	$250	$2650
220	$3200	$250	$2950
240	$3500	$250	$3250

Estimated Dental
Procedure Minutes

Total Prepaid Fee

Deposit due at scheduling

Balance due prior to procedure

$450

$250

$200

$525

$250

$275

$650

$250

$400

$850

$250

$600

$1050

$250

$800

$1350

$250

$1100

100

$1550

$250

$1300

120

$1800

$250

$1550

140

$2100

$250

$1850

160

$2350

$250

$2100

180

$2600

$250

$2350

200

$2900

$250

$2650

220

$3200

$250

$2950

240

$3500

$250

$3250

Payment Policy:

$250 Deposit is due at the time of scheduling. There is a $250 charge for patients who fail to keep the IV
Sedation appointment without giving us a 24 hour notice.

The card on file will be charged automatically for the balance 2 business days prior to the procedure date.

On the day of the patient’s procedure, you will be given a Superbill to file the anesthesia through your out of network benefits.
Many medical insurance companies do not cover anesthesia services for office based dental care.

Your dental treatment plan may change after treatment is begun. Charges for anesthesia services may
be more or less than the estimated amount based on the final length of the procedure. The anesthesia
charges may be more than initially estimated and an additional payment by credit card is due at the
time of service. Any overpayments will be refunded automatically to you.

We accept cashier’s check, American Express, Discover, Visa, MasterCard, and Carecredit for payment
in full 3 business days before the patient is treated. You can apply for Carecredit at www.carecredit.com

I authorize PDAA to send me text messages via SMS texting regarding my child's anesthesia appointment and finances. I understand standard text message and data rates may apply.

I understand that my health plan (Tricare and other plans) may impose a limit on balance billing by out of
network providers. I wish to waive any limit on balance billing and receive treatment from this out of network
provider.
I understand that I am seeking the care of PDAA for a service that may not be covered by my insurance
company. I understand that my insurance plan may not cover any part of the charges, costs or expenses
related to Anesthesia services and I will be responsible for all charges incurred.

April 26, 2024

Dentist Name

Procedure Date

Patient Last Name

Patient DOB

Patient First Name

Gender

Patient Nickname

Address

City

State

Zip

Parent Name

Email address

Work Phone

Home Phone

Cell Phone

I prefer to be contacted by:

Order ID:

Redfin ID:

Today's Date

Parent Name:

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Your legal name

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Timestamp

Audit

September 20, 2022 10:37 am EDT

test Uploaded by Pediatric Dental Anesthesia Associates - billing@pediatricsedation.com IP 182.77.57.214