Child Dental Benefits Schedule Bulk Billing Patient Consent Form

Child dental benefits bulk billing consent

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;f
of the likely cost of this treatment; and
That I will be bulk billed for services under the 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 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.

Parent's Medicare number(Required)

Parent/Legal Guardian Signature(Required)

Patient's full name(Required)

Full name of person signing (if not the patient)(Required)

Date(Required)

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Child dental benefits bulk billing consent

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