MEDICAL ASSISTANCE PROGRAM WAIVER

The Minnesota Medical Assistance program exists to assist people with basic medical and dental care. The dental program covers routine exams, x-rays, cleanings, fluoride treatments, amalgam fillings, composite fillings on front teeth, partial dentures, full dentures, extractions, and stainless steel crowns. It does not cover composite fillings in back teeth, permanent crowns, or non-standard partial dentures or full dentures.

If you choose to have services that are not covered by the Medical Assistance program, you will be financially responsible for the costs. Also, due to state budget limitations, the program has limited services to $500/year, so you will be financially responsible for any costs over $500.

Our general financial policy is payment in full at the time of service. Crowns require a down payment of ½ at the first appointment, and the second ½ at the second appointment.

Not-covered services desired (tooth, service, cost):

_________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________

I have read the above statements and fully understand them. I agree to have Dr. Ronald L. King perform the above listed services which are NOT covered under the Medical Assistance Program, and I will pay for them in full at the time of service.

Patient name: ________________________________________

Patient signature: _____________________________________ Date: ____________

Witness name: _______________________________________

Witness signature: ____________________________________ Date: ____________

Ronald L. King, DDS 6100 Excelsior Blvd, Suite East St. Louis Park, MN 55416 Phone: 952-929-4545

FAX: 952-929-4592 e-mail: kingtooth@juno.com Web site: www.kingtooth.com