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Dental treatment estimate letter for patients

A free dental treatment estimate letter for patients: what insurance should pay, what they will owe, and why the final amount can change.

Updated November 11, 2026

How to use it

Give it to the patient with the treatment plan, before the visit, and keep a signed copy. It sets the expectation that the estimate isn't a promise of what the insurer pays.

Fill in each line from the plan's coverage, deductible left and yearly maximum left. Tabruns works these out from the benefits page, line by line.

The template

Fill in the [brackets] in your own copy. This page has no fields: nothing you'd fill in is typed here.

[Office name]
[Office address] | [Office phone]
[Date]
Dear [patient name],
Here is our estimate for the treatment Dr. [dentist name] recommended, and how much we expect your dental insurance to pay.
Your treatment
[Service] on tooth [tooth number]: fee $[fee], insurance estimate $[insurance share], your estimate $[patient share]
[Service] on tooth [tooth number]: fee $[fee], insurance estimate $[insurance share], your estimate $[patient share]
Total: fee $[total fee], insurance estimate $[total insurance], your estimate $[total patient]
How we worked it out
Your plan, [insurer and plan name], pays [percent]% for [kind of service] after the deductible. Your deductible left this year is $[deductible left], and your plan's yearly maximum left is $[maximum left].
Why the final amount can change
This is an estimate, not a guarantee. Your insurance company decides what it pays when it processes the claim. The amount can change if:
- another claim uses part of your deductible or yearly maximum first,
- your plan has a limit or rule we couldn't see when we checked,
- your coverage changes before the treatment.
If your insurance pays less than we estimated, the difference is yours to pay. If it pays more, we'll refund or credit you.
Payment
Your estimated share of $[total patient] is due [when: at the visit / at each visit]. [Payment plan or financing options, if any.]
Questions? Call [contact name] at [phone].
I have read this estimate and understand it is not a guarantee of payment.
Patient or guardian signature: ________________ Date: ________

A starting point, not legal advice. Check it against your state's rules and your network contracts.

Sources

Read November 11, 2026. Where a source describes one insurer's plans, we say so.

Get the patient's share in dollars, from the benefits page

Tabruns fills in the coverage, maximum, deductible and limits from the portal for you. Tabruns reads the coverage, deductible, yearly maximum, waiting periods and frequency limits from the insurer's portal and works out what the patient owes. Patient details stay on the office computer.

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Not ready? Try the free patient portion calculator.

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