Grand Rapids Office
1179 East Paris Ave SE
Suite 220
Grand Rapids, MI 49546
(616) 957-3977
Muskegon Office
433 Seminole Rd
Suite 205
Muskegon, MI 49444
(231) 737-0001

 

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New Patients Forms 
Consent for Use and Disclosure 


*Please ensure you use adequate postage and keep a copy of the entire application for your records.

**Because of the high volume of applications and need for orthodontic care Winning Smiles Orthodontics acceptance policies are very strict.  If your application is incomplete in any way, it will be rejected and returned to you.  If you wish to reapply you will be required to submit a new application with an additional $30 application fee.

***Additional documentation for non-parental guardians
  • Non-parental guardians must also submit a copy of their authorization to make medical decisions.
  • For children in state custody, copies of the child's state medical card and medical consent must also be submitted.

TREATMENT FEES:  Fees will be determined at the Initial Consultation.  Please feel free to print the downloadable New Patient form, Consent for Use and Disclosure form and the Foundation Application.  Please mail ALL forms to us COMPLETED or they will be returned and your application will be denied.  If applying for the Foundation, these forms must be turned in to us prior to scheduling a New Patient Exam.

*Subjct to a $30 application fee

*All Applications received will be subject to the most current fee structures regardless of the fees specified on the Application submitted.

**Treatment fees include initial records, orthodontic treatment with traditional braces, clear retainers and final records.  Additional fees may be charged for other orthodontic devices or appliances required such as a palatal expansion appliance if necessary.

***Basic qualifications for the Foundation include:

  • Must be between the ages of 10-25
  • Must live in Kent, Muskegon or surrounding Counties
  • Must be employed or on Permanent Disability and provide your Federal Tax Returns (1040's) and W-2's or your SSI Awards Letter
  • Must be in good Oral Standings

CHARITY CARE PROGRAM:  Applicants with severe orthodontic needs and little or no finances are eligible for our Charity Care Program. They are often referred by Social Service Agencies and other nonprofit organizations within the community.

REDUCED-COST PROGRAM:  We use a sliding fee scale based on the most recently published Federal Poverty Guidelines.

INSURANCE:  We participate with Aetna DMO, Delta Dental Direct, PPO, DMO and EPO and Metlife.  *We accept all insurance.

PERSONS WITH ORTHODONTIC INSURANCE COVERAGE :  Any additional insurance benefit available will be applied to the discounted portion of the orthodontic treatment fee.  We will apply a 10% discount to your portion of the treatment fee once there is an orthodontic insurance payment applied to the account.

PAYMENT PLANS:   Payment plans vary based on treatment fees. We will discuss payment plans at the Initial Orthodontic Exam.

NOTE:  Winning Smiles Orthodontics provides for orthodontic treatment ONLY.  Extractions, cleanings, oral surgery or other treatment that may be necessary before, during or after orthodontic treatment are the financial responsibility of the patient's parents or guardians.

 
FREQUENTLY ASKED QUESTIONS
 
Is the Dental Referral Form required?
YES.  The Dental Referral form is required and must be filled out by the patient's general dentist based on a dental visit no more than 6 months prior to the date of the application.  The dental referral forms must indicate good oral hygiene, no unfilled cavities and fewer than four 4 baby teeth.  If you have an upcoming appointment scheduled for your 6 months cleaning and this appointment lands after the consultation date you may keep the consultation appointment and send this dental referral in once the cleaning is complete.  The dental referral form MUST BE turned in to us to be accepted and for treatment to begin.
 
Can my child still be accepted if I don't submit my tax information?
NO.  A copy of the most recent year's Federal Tax Forms 1040/1040A or a current SSI awards letter is REQUIRED.  There is NO exception to this policy.  Applications submitted without tax information or with forms that have been altered in any way will not be accepted.  Also required are the most recent year's W-2's.
 
I have more than one child in need of braces.  Do I have to submit a seperate application for each of them?
YES.  A seperate Application, Tax/SSI forms, Dental Referral form and $30 application fee is required for each patient who is applying to receive treatment through Winning Smiles Orthodontics Foundation.
 
Is the $30 application fee refunded if we are not accepted into the program?
NO.  The $30 application fee is used to determine if you qualify for the program.  This fee is not refunded to you whether you are accepted or not.
 
If I pay the initial fee to start treatment and then decide I do not want to go forward with treatment, can I get this initial fee refunded?
NO.  The initial fee is NON-REFUNDABLE.  This fee is used for the Records, Diagnostic and Treatment Planning expense.  This process is very time consuming and costly, therefore once the fee is paid you must either commit to treatment or forfeit the initial fee.
 
Can I make payments on the Initial Fee?
YES.  You may make payments towards the initial fee but appointments will not be scheduled for Records and to have the braces placed until the full initial fee is received.  Any money paid toward the Initial Fee will be NON-REFUNDABLE.
 
Can I get Invisalign or Cosmetic (Clear) braces through this program?
NO & YES.  We do not offer Invisalign at our practice but we do offer Cosmetic brackets at an additional fee of $300 per arch.  For upper and lower Cosmetic brackets the fee would be $600.  This additional fee is due up front and will not be broken into payments.
 

Thank You!

We are only able to achieve our goals because of the amazing generosity and support of our partners... 

 Re  

Ormco

Ortho2

Huntington

Henry Schein

Henry Schein Orthodontics

Rocky Mountain Orthodontics

Reliance Orthodontic Products

Hungerford Nichols CPAs   + Advisors

 

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