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Free Dental

Free No-out-of-pocket dental through Medicare Child Dental (CDBS) for eligible students.

What’s included?
✓ Dental exam
✓ Teeth cleaning
✓ Fluoride treatment
✓ X-rays
✓ Protective tooth sealants
✓ Fillings

Does your child (the student) have any of the following conditions? Please tick ‘Yes’ or ‘No’ for each option.

1. Privacy and Consent

I have read and understood the privacy information on page 4. I acknowledge and agree to how the program will manage student healthcare information.

2. Medicare Consent and Dental Treatment Authorisation

• I have read and understood the Medicare Bulk Billing section of this form, including the safety and benefits of the dental check-up and preventive care treatments as outlined at www.adhv.com.au/dentaltreatment. I have had an opportunity to ask questions and seek clarification on the information I have been provided by calling ADHV on (03) 9323 9607.
• I understand that I DO NOT have to pay these costs and that they will be deducted from my child's CDBS Medicare balance.
• I give consent to ADHV to provide dental treatment to my child including a Comprehensive dental examination (Item 88011) I understand if my child requires a clean (Item 88111 or 88114) and/or remineralisation (Item 88121) for their teeth, I give further consent.
• If my child is not Medicare eligible, I understand ADHV will provide a Pro-bono dental health screening and report for selected students.
• If required, ADHV may return every six months to provide a dental check (Item 88012 or 88013), professional clean (Item 88115), and remineralisation with fluoride (Item 88121)

3. Small Dental X-Rays (Item 88022)

Significantly increase the detection of tooth decay and are safe for people of all ages. I give consent to take up to 2 small dental x-rays for diagnosis if they are required.

4. Fissure Sealants are a coating/seal that help prevent cavities on teeth (Item 88161 & 88162)

I also consent to place seals on my childs teeth (molars) if they are required (up to 4 seals

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;

Of the likely cost of this treatment; and

That I will be bulk billed for services under 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 to 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 / will need to personally meet the costs of any additional services once benefits are exhausted.

 

ADHV will Not charge any out of pocket costs for services completed.

This form is valid up to 31 December of the calendar year for which it is signed.