WHAT TO EXPECT AT YOUR APPOINTMENT
(Uninsured Patients)
- If you need to reschedule, please call us more than 24 hours before your appointment.
- If the appointment is for a child under 18 years, please bring all vaccination records. The child does not need to be present for the financial screening appointment.
- Please bring a completed financial screening form.
- If you are unable to complete the financial screening form in advance, please arrive 25 minutes early for your appointment.
- Along with the completed financial screening form, please bring the following items with you:
- Your photo ID
- Proof of household income for last two months such as:
- Consecutive pay stubs (8 stubs for weekly pay/4 stubs for every other week pay)
- Most recent signed 1040 tax return
- Letter from employer on letterhead stating hours worked per week and rate and frequency of pay
- Social Services or Social Security Administration Agency letter on letterhead (such as notice of unemployment, disability or retirement benefits)
- Notarized support letter from individual providing financial assistance
- Most recent Food Stamp award letter (not EBT card)
- For a complete list with full detail, please refer to the financial application form. Additional forms you may need are available on the Forms page.
Please arrive 15 minutes early for your appointment.- If you need to reschedule, please call us more than 24 hours before your appointment.
- Your insurance card (if applicable) and a photo ID.
- Medication registration form (if you are a Medicaid patient): print and download here or complete online here.
- A list of any questions you have about your health. Put the questions most important to you at the top of the list.
- All of your medications in their original containers, including prescription, over the counter, natural, and herbal medications and dietary supplements.
- A list of other healthcare providers you have visited. Write down their contact information and the reason for your visit with them.
Cancellation and No-show policies
If you need to cancel or reschedule an appointment, please call more than 24 hours before your appointment. If we are not open when you call, you can leave a message on our appointment cancellation voicemail. Any appointment canceled or rescheduled with less than 24 hours notice is considered a broken appointment.
Scheduling a Dental Clinic Appointment
Dental services are not immediately available to newly screened medical patients. Patients new to CrossOver must first complete a primary care appointment. After the patient completes the primary care visit and being cleared for dental services, a dental appointment may be scheduled. Dental cleaning appointments are offered to new patients before any other dental service appointment. If your primary care clinician feels you have an emergency situation, he or she will contact the dental coordinator directly to schedule an appointment sooner. All patients must have at least one in-person primary care visit each year to remain eligible for dental services.
Dental Cancellation and No-Show Policy
If you need to reschedule a dental appointment, please call the clinic and leave a message at least 24 hours before your appointment time. If you miss an appointment, call to reschedule less than 24 hours before your appointment, or arrive more than 15 minutes late, this is considered a broken appointment. Only one broken appointment is allowed in a six-month period, and only two cancellations/reschedules are allowed in a 12-month period. After the second broken appointment or third reschedule, you may not schedule dental appointments except for same-day appointments when they are available for a period of 1 year. Missing a same-day appointment may result in a one-year probation from the dental program.
RECOMMENDED CONTRIBUTIONS FOR UNINSURED PATIENT SERVICES
(effective 7/1/2025)
| Service | Amount |
| Medical Visit | $25 |
| Same Day Visit | $30 |
| Nurse Visit or Labs | $20 |
| Vision Visit | $25 |
DENTAL CONTRIBUTIONS
FOR SERVICES
| Service | Amount |
| Dental Level I – Diagnostic | $40 + x-rays |
| Dental Level I – Hygiene | $50 – $70 |
| Dental Level II – Extractions Routine or Surgical | $75 – $80 per tooth |
| Dental Level III – Restorative/ Fillings | $75 per tooth |
*For Medicaid Patients: If you receive dental services not covered by your Medicaid plan, you will be asked to make a contribution toward the cost of the service.
RECOMMENDED CONTRIBUTIONS FOR UNINSURED PATIENT SERVICES
(effective 7/1/2025)
| Service | Amount |
| Medical Visit | $25 |
| Same Day Visit | $30 |
| Nurse Visit or Labs | $20 |
| Vision Visit | $25 |
DENTAL CONTRIBUTIONS
FOR SERVICES
| Service | Amount |
| Dental Level I – Diagnostic | $40 + x-rays |
| Dental Level I – Hygiene | $50 – $70 |
| Dental Level II – Extractions Routine or Surgical | $75 – $80 per tooth |
| Dental Level III – Restorative/ Fillings | $75 per tooth |
*For Medicaid Patients: If you receive dental services not covered by your Medicaid plan, you will be asked to make a contribution toward the cost of the service.
(Uninsured Patients)
- If you need to reschedule, please call us more than 24 hours before your appointment.
- If the appointment is for a child under 18 years, please bring all vaccination records. The child does not need to be present for the financial screening appointment.
- Please bring a completed financial screening form.
- If you are unable to complete the financial screening form in advance, please arrive 25 minutes early for your appointment.
- Along with the completed financial screening form, please bring the following items with you:
- Your photo ID
- Proof of household income for last two months such as:
- Consecutive pay stubs (8 stubs for weekly pay/4 stubs for every other week pay)
- Most recent signed 1040 tax return
- Letter from employer on letterhead stating hours worked per week and rate and frequency of pay
- Social Services or Social Security Administration Agency letter on letterhead (such as notice of unemployment, disability or retirement benefits)
- Notarized support letter from individual providing financial assistance
- Most recent Food Stamp award letter (not EBT card)
- For a complete list with full detail, please refer to the financial application form. Additional forms you may need are available on the Forms page.
- Please arrive 15 minutes early for your appointment.
- If you need to reschedule, please call us more than 24 hours before your appointment.
- Your insurance card (if applicable) and a photo ID.
- Medication registration form (if you are a Medicaid patient): print and download here or complete online here.
- A list of any questions you have about your health. Put the questions most important to you at the top of the list.
- All of your medications in their original containers, including prescription, over the counter, natural, and herbal medications and dietary supplements.
- A list of other healthcare providers you have visited. Write down their contact information and the reason for your visit with them.
Cancellation and No-show policies
If you need to cancel or reschedule, please call more than 24 hours before your appointment. If we are not open when you call, you can leave a message on our appointment cancellation voicemail. Any appointment canceled or rescheduled with less than 24 hours notice is considered a broken appointment.
Dental Cancellation and No-Show Policy
If you need to cancel or reschedule your appointment, please call more than 24 hours before your appointment.
Any dental appointment canceled or rescheduled with less than 24 hours notice is considered a broken appointment. Patients are allowed one (1) broken appointment in a six-month period. If a patient has three (3) broken appointments in a twelve-month period, they cannot schedule future dental appointments but may call to schedule a “same day” appointment if one is available.