Skip to Content
image
image
image
image
image
  • Patient Information
  • Dental Insurance Coverage
  • Please note that the insurance coverage is between you, your employer and the insurance co. We file for payment on your behalf.
    Our office is not responsible for keeping up with waiting periods, deductibles, frequencies, maximums, downcoding * and copays
    *Downcoding is big with insurance and it is when an insurance assigns a different code to a treatment that was done.
    If this is done - it is the patient's responsibility to pay the difference, as well as, estimated copays and deductibles are due at the time of service.

  • Acknowledgement of Receipt of Notice of Privacy Practices of Eric T. Moskowitz, DDS, PA

    Notice to Patient: We are required to provide you with a copy of our Notice of Privacy Practices, which states how we may use and/or disclose your health information. By signing below, you acknowledge receipt of the Notice. You may refuse to sign this acknowledgement. I acknowledge that I have received a copy of this office's Notice of Privacy Practices.

  • I authorize the dentist/employees to discuss my treatment with the following. I may revoke this at any time in writing.

  • Financial Agreement and Release:

    By signing below, I authorize the dentist (or dentist's employees) to and understand the following:
    * Perform diagnostic procedures and dental treatment as may be necessary for proper dental care.
    *Release of any information concerning my/my childs health care, advice and treatment provided for the purpose of evaluating and administering claims for insurance
    *Release of information concerning my/my childs health care, advice and treatment to another dentist, if needed.
    *Authorize payment of insurance benefits directly to the dentist which otherwise may be payable to me.
    *I am responsible for and agree to pay the total cost of dental services, regardless of any insurance benefits and/or pymts.
    *I agree to pay all deductibles and estimated copays on the date of service. I also agree to pay any unpaid balance after insurance.
    *Appointment times are reserved exclusively for me. *I am responsible for a fee of $50 for any late cancellations (less than 24 hours)/missed/or no show appts.
    *The office accepts Discover, American Express, Mastercard, Visa, Checks and cash. $25 fee for any returned check.