405 Franklin Ave Franklin Square, NY 11010

Patient Forms

HIPPA RELEASE FORM

The Health Insurance Portability and Accountability Act, also known as HIPAA, was created in 1996 by the US Congress to protect the privacy of your health information. The act prohibits your health care providers from releasing your health care information unless you have provided your health care provider with a HIPAA release form.

Unless you have provided a signed release form, your health care providers are prohibited from discussing any aspect of your medical information with anyone who is not directly involved in your care.

NEW PATIENT INFORMATION FORM

To save time at your first visit, download and complete the New Patient Information form ahead of time, and we’ll get you started even faster.

DENTAL INSURANCE

We are happy to process your insurance claims to maximize your benefits. Since insurance can be confusing, we ask that you call or contact us with specific questions. Because insurance policies vary, we can only estimate your coverage in good faith but cannot guarantee coverage due to the complexities of insurance contracts. As a service to our patients, we will bill insurance companies for services. You are responsible for the copayment at the time of service and are fully responsible for whatever your insurance carrier does not pay. If you have any questions, our courteous staff is always available to answer them.

We currently accept all PPO/PDP plans.