Patient Advocacy Agreement
By enrolling in the Dental Grants Program, you hereby consent to the following terms of the Patient Advocacy Agreement herein.
Please take a moment to understand the following terms as they are the conditions upon which we will consent to your participation in the program and advocate on your behalf with the dentist.
The Applicant understands that a qualified dental professional will be assigned to your file to advocate on your behalf with the dentist. In order to make sure all of our combined efforts are successful, Applicant agrees to maintain regular communication with their Advocate and will respond to payment schedules, emails, text messages and phone calls in a timely and responsible manner.
The Applicant understands that the Grant will only cover up to 25% of the dentist’s fees and that the Dental Grants will not pay for 100% of your dental services and you will be responsible for the part of your dental treatment not covered by the Grant.
Goodwill and Respect for Participating Dentists:
When we schedule an appointment for you to attend at the Dentist’s office for your initial consultation, it is ESSENTIAL that you attend and show up on time as the appointment will be scheduled especially for you.
Initial consultations with the dentist are free. Consultations consist of a 15 or 20 minute discussion so the dentist can learn about your primary concerns.
Exam and X-rays Fees:
Examinations and/or X-rays may be necessary in order for the dentist to properly diagnose any pre-existing problems with your mouth, gums and teeth so they can put together a proper estimate of the cost to complete the dental work you want done.
If you require a full exam and/or x-rays, the dentist will charge an exam and x-ray fee which may cost anywhere from $133 to $450, depending on the type of exam.
Accordingly, Applicant understands that he or she is responsible for paying the examination and/or x-ray fee if/when applicable.
Consent to Share Dental Records and Treatment Plan Information
Pursuant to the Personal Health Information Protection Act in your jurisdiction, you hereby consent to the participating dental office disclosing information to your Patient Advocate such as your dental records, treatment plan information and all other information that is relevant in order for your Patient Advocate to represent your best interests.
Making Installment Payments for Your Dental Work:
Subject to certain criteria, you may make installment payments for the part of your dental work that's not covered by the Grant if you enroll in our Patient Plus+ Program prior to receiving any dental work. When you enroll, we will pay the dentist upfront for your dental work that's not covered by the Grant, and allow you to make payment installments. This ensures that there are fewer obstacles for you to start treatment.
Accordingly, if you enroll in the Patient Plus+ Program, you agree to the Payment Plan Program Agreement and agree to provide HBI with any requested financial information that supports your ability and willingness to make your installment payments responsibly and at agreed upon times using acceptable methods of payment.
Treatment Plan Estimates:
You have no obligation to proceed with treatment if you are not satisfied with the dentist or the treatment plan, however once a treatment plan has been accepted, you should be prepared to begin treatment within 30 days and to make your payments as agreed.
Thank you for helping to make the Dental Grants Program a success.