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Estimated Dental Procedure Minutes	Total Prepaid Fee	Deposit due at scheduling	Balance due prior to procedure
5	$390	$250	$140
20	$550	$250	$300
40	$775	$250	$525
60	$975	$250	$725
80	$1200	$250	$950
100	$1400	$250	$1150
120	$1650	$250	$1400
140	$1900	$250	$1650
160	$2150	$250	$1900
180	$2400	$250	$2150
200	$2700	$250	$2450
220	$2900	$250	$2650
240	$3200	$250	$2950

Estimated Dental
Procedure Minutes

Total Prepaid Fee

Deposit due at scheduling

Balance due prior to procedure

$390

$250

$140

$550

$250

$300

$775

$250

$525

$975

$250

$725

$1200

$250

$950

100

$1400

$250

$1150

120

$1650

$250

$1400

140

$1900

$250

$1650

160

$2150

$250

$1900

180

$2400

$250

$2150

200

$2700

$250

$2450

220

$2900

$250

$2650

240

$3200

$250

$2950

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 a 24 hour notice.

Our financial office can help patients with medical insurance determine their out of network benefits. On the
date of service 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, however, PDAA
is commuted to fully assisting you with the pursuit of any potential reimbursement.

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 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.

Parent/Guardian:

Date: October 8, 2024

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Timestamp

Audit

February 27, 2021 12:09 pm EDT

Online Scheduling (Old) Uploaded by Pediatric Dental Anesthesia Associates - alan.campbell@castawaylabs.com IP 47.201.198.107

March 3, 2021 8:35 am EDT

Pediatric Sedation - billing@pediatricsedation.com added by Alan Campbell - alan.campbell@castawaylabs.com as a CC'd Recipient Ip: 47.201.198.107

March 3, 2021 8:35 am EDT

Alan Support - alan.campbell@castawaylabs.com added by Alan Campbell - alan.campbell@castawaylabs.com as a CC'd Recipient Ip: 47.201.198.107

March 4, 2021 9:09 pm EDT

Pediatric Sedation - billing@pediatricsedation.com added by Pediatric Dental Anesthesia Associates - alan.campbell@castawaylabs.com as a CC'd Recipient Ip: 47.201.198.107

March 4, 2021 9:09 pm EDT

Alan Support - alan.campbell@castawaylabs.com added by Pediatric Dental Anesthesia Associates - alan.campbell@castawaylabs.com as a CC'd Recipient Ip: 47.201.198.107

March 5, 2021 8:12 am EDT

Pediatric Sedation - billing@pediatricsedation.com added by Pediatric Dental Anesthesia Associates - alan.campbell@castawaylabs.com as a CC'd Recipient Ip: 47.201.198.107

March 5, 2021 8:12 am EDT

Alan Support - alan.campbell@castawaylabs.com added by Pediatric Dental Anesthesia Associates - alan.campbell@castawaylabs.com as a CC'd Recipient Ip: 47.201.198.107

Dental Office	Procedure Date
Patient Last Name	Patient First Name
Patient DOB	Gender
Parent Info
Address	City
State	Zip
Primary Phone	Secondary Phone
Email address
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Anesthesia Fee Estimate Form

Estimated anesthesia minutes given by dentist:

Payment Policy:

Anesthesia Fee Estimate Form

Estimated anesthesia minutes given by dentist: minutes520406080100120140160180200220240

Payment Policy:

Estimated anesthesia minutes given by dentist: