Dental Patient Payment Notice

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July 2016

CrescentCare is required to collect all copays, deductibles, and sliding fee payments where applicable.
CrescentCare offers a sliding fee discount to patients whose incomes fall at or below 200% of the Federal Poverty Guidelines.† Each year the federal government establishes income levels that qualify patients to be eligible to pay reduced costs for services. Sliding fee means that costs change according to the patient’s income, lack of income, or ability to pay. Patients that qualify are eligible for a sliding discount on fees for all services provided at CrescentCare.† †

If you have insurance, we will charge you according to the guidelines of your insurance plan (for copays and deductibles).†† All labs will be billed directly to your insurance plan by the lab company.† The lab company will then bill you directly for any outstanding balance.† If you do not want to bill your insurance for services we can still see you. You will be considered self-pay and are responsible for your charges. Charges for supplies and equipment such as crowns and dentures will be charged separately.† Please request a treatment plan from your dental provider before starting the work, so that you know how much the services will cost.† Please ask our staff if you would like to work out a payment plan.

2016 Federal Poverty Guidelines & CrescentCare Sliding Fee Discount for Preventative Dental
Persons in Household Group A
Family Annual Income: at or below 100% FPL
Group B
Family Annual Income: 101% up to 150% FPL
Group C Family Annual Income: 151% up to †175%† FPL Group D Family Annual Income: 176% up to 200% FPL Group E Family Annual Income: over 200% FPL

1

11,880

17,820

20,790

23,760

23,761 +

2

16,020

24,030

28,035

32,040

32,041 +

3

20,160

30,240

35,280

40,320

40,321 +

4

24,300

36,450

42,525

48,600

48,601 +

5

28,440

42,660

49,770

56,880

56,881 +

6

32,580

48,870

57,015

65,160

65,161 +

7

36,730

55,095

64,278

73,460

73,461 +

8

40,890

61,335

71,558

81,780

81,781 +

For families/households with more than 8 persons, add $4,160 for each additional person.

Discount Applied

100%

50%

25%

15%

0%

Patient Responsibility:
Preventive Care

Nominal Preventive Dental Fee ($45)

See staff for approximate visit amount

See staff for approximate visit amount

See staff for approximate visit amount

See staff side for approximate visit amount

Patient Responsibility:
Fixed Dental

Nominal Fee for Fixed Dental ($400)

†See staff for approximate visit amount

See staff for approximate visit amount

See staff for approximate visit amount †

†See staff for approximate visit amount

Patient Responsibility: Removable Dental

Nominal Fee for Removal Dental ($500)

†See staff for approximate visit amount

See staff for approximate visit amount

See staff for approximate visit amount

See staff for approximate visit amount

CrescentCare offers additional assistance for HIV positive patients through the Ryan White Program.

If you are HIV+, please meet with a Case Manager to determine eligibility.† Ryan White services apply to individuals at or below 500% of the Federal Poverty Guidelines.† The Ryan White program has a separate sliding scale discount.

All of CrescentCare’s sites serve all patients regardless of their ability to pay. Our staff can screen you and help you to enroll in benefits. Please speak with one of our staff for more detailed information.

 

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