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Click on the links below to submit online or view and/or save these form files in PDF format. Fill out the forms and email to Dr.Seiden@mobiledreams.net or fax to (773) 825-8534.

Payment

 
To submit payment for a deposit, please select Anesthesia Deposit below. The full total depends on the length of procedure being performed and will be confirmed after the appointment, but the dental office may have a time estimate for the treatment that can be used to create an estimate for the anesthesia fee. Please contact the dental office for more information on their time estimate. The non-refundable deposit  will serve to secure your appointment. Once the deposit is received, your appointment will be confirmed. Full payment is required on the day of surgery. 

Insurance coverage

If you have private medical insurance (for example Aetna, Blue Cross, Kaiser), medical insurance sometimes will cover the anesthesia fees. You should contact your insurance provider if you wish to explore this coverage. Mobile Dreams does not bill insurance, so if you have private medical insurance you will be responsible for the anesthesia fee at the time of your appointment. Mobile Dreams is able to provide documentation needed to attempt reimbursement from medical insurance. Please note that it is typically your medical insurance, not your dental insurance, that may possibly provide reimbursement for anesthesia services.

Special program for children with intellectual disabilities/developmental delay

For children who have a documented intellectual disability or developmental delays, The Humanitarian Foundation of Grottoes International may be able to help pay for dental treatment and anesthesia. View their program eligibility requirements for more information.

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