Healthcare Extraction Estimate

Healthcare Extraction Estimate

Practice and Provider

Patient Information

Patient Name:

Date of Birth:    Gender: Male Female Other

Insurance Information

Medical History (Relevant to Extraction)

Proposed Extraction Procedure & Clinical Details

Tooth / Site Identified:

Procedure Description:

Extraction Type: Simple Surgical Impacted

Anesthesia / Sedation: Local Local with Sedation General

Itemized Estimate of Charges

Surgical / Extraction Fee:

Anesthesia / Sedation Fee:

Facility / Operatory Charge:

Supplies / Materials:

Pathology / Lab (if required):

Additional / Other:

Payment Terms and Fees

Deposit Required: Yes

If deposit required, Amount:

Balance Due: Payment in full is required at the time of service for patient-responsible amounts not covered by insurance. Insurance estimates are not guarantees of payment.

Risks, Benefits, and Alternatives

Risks associated with dental extractions may include, but are not limited to: infection, bleeding, dry socket, nerve injury, sinus communication, swelling, bruising, altered sensation, need for additional procedures, and adverse reaction to medications or anesthesia. These risks are described to the best of the provider's knowledge based on the presenting condition.

Anticipated benefits include relief of pain or infection and resolution of the indicated dental problem. Reasonable alternatives to extraction include restorative treatment, endodontic therapy, observation, or referral for specialty care where appropriate.

I acknowledge that I have had the opportunity to ask questions about the procedure, risks, benefits, alternatives, and anticipated costs. I understand that the clinical situation may change during the procedure and that additional services or charges may become necessary. This estimate does not constitute a guarantee of results or insurance coverage.

HIPAA / Privacy Acknowledgment & Authorization

I acknowledge receipt of the practice's Notice of Privacy Practices and authorize the release of medical information to my insurance company and referring providers as necessary for treatment, payment, and healthcare operations as described. I understand that this estimate contains protected health information and that further authorization may be required for other disclosures.

I authorize the practice to bill my insurance and to provide any necessary information to obtain payment. I understand that I am financially responsible for charges not paid by my insurer.

HIPAA Acknowledgment: I acknowledge receipt of the Notice of Privacy Practices.

Certification of Estimate

This document constitutes a good-faith estimate of the anticipated services and charges related to the proposed extraction based on the information available at the time of preparation. It is not a contract and is subject to change if clinical findings differ at the time of treatment or if the insurer determines different coverage. The patient remains responsible for all amounts not paid by insurance, including deductibles, co-payments, co-insurance, and services denied as not covered.

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