Medicare Fees

Dental Examination: 88011 ($57.65) or 88012($47.90)
Xrays if required: 88022 ($33.35 each)
Cleaning: 88111($58.90) or 88114 ($98.20) or 88115 ($63.85)
Remineralisation Treatment (Fluoride): 88121 ($37.85)
Fissure Sealants - (Sealant in grooves of back molars to help prevent tooth decay) if required: 88161($50.45 per tooth 

I agree that I have, to the best of my knowledge, provided by NSW Dental Care with all the relevant health and personal information that is required to provide appropriate care.

Parent / Guardian Details

                               

                                       CHILD DENTAL BENEFITS SCHEDULE
                                    BULK BILLING PATIENT CONSENT FORM

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 I will need to personally meet the costs of any additional services once benefits are exhausted.