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In an effort to provide you with quality Dental Care and maintain our present fees by minimizing billing procedures, Payment is requested at the time of your visit.

    Please check one:

Payment by cash
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Financial arrangements can be made upon request. If the following options are chosen, a (SEPARATE APPLICATION FORM IS NEEDED). Please request one. Our office is fully approved and accredited user of the Visa/MasterCard Health Care Incentive Program which will enable you to use your Visa/MasterCard (or American Express) to automatically cover amounts not paid by your insurance. You may also choose a comfortable amount to be automatically billed to your Visa, MasterCard, American Express, or checking account on a monthly basis.

IF YOU HAVE DENTAL INSURANCE, A COMPLETED DENTAL CLAIM FORM MUST BE ON FILE WITH THIS OFFICE. IT IS ALSO YOUR RESPONSIBILITY TO NOTIFY US OF ANY CHANGES. FOR INVOLVED TREATMENT GREATER THAN ($250), WE WILL ACCEPT YOUR INSURANCE ASSIGNMENT TOWARDS YOUR BILL AS LONG AS A DEFINITIVE ARRANGEMENT IS MADE FOR YOUR CO-PAYMENT PORTION. CHOOSE AN OPTION ABOVE.


If you would rather mail us this form, simply fill out each field and then print this page by selecting the Print option on your File menu otions above. Then sign the form and mail it to the address below.

    29 WEST DENTAL ASSOCIATES
    29 West 57th Street, 6th Floor
    New York, N.Y. 10019
    Ph (212) 838-2900
    Fax (212) 935-4703


Your insurance is a method for you to receive reimbursement for fees you have paid to the doctor for services rendered. Having insurance is not a substitute for payment. Many companies have fixed allowances or percentages or other limitations based on your contract with them. It is your responsibility to pay the deductible, co-insurance, and any other balances not paid for by your insurance. We will assist you in receiving reimbursement as much as possible, but you are responsible for your bill.

Signature of Patient _____________________________________