It is your responsibility to provide all necessary insurance eligibility, identification, authorization, and
referral information (when necessary for medical based claims) and to notify our office of any information changes
when they occur. Even a preauthorization of services does not guarantee payment from your insurance carrier. We also
require photo identification when accepting insurance information. It is each patient’s responsibility to know if
our office is participating or non-participating with their insurance plan. Failure to provide all required
information may necessitate patient payment for all charges. When insurance is involved, we are contractually
obligated to collect copayments, coinsurance, and deductibles, as outlined by your insurance carrier.
Please be aware that some insurance carriers may prohibit assignment of benefits and may try to limit their
financial liability with arbitrary limits, exclusions, or reductions such as reasonable and customary or usual and
prevailing reductions. Our fees are well within such ranges and although we will assist in the filing of an appeal
if these limitations are imposed, you as the guarantor are responsible as indicated by your employer’s or your
insurance company contract.
Miscellaneous Forms, Additional Information and Authorizations
We will provide all necessary information to have your benefits released. However, if it becomes necessary to submit
redundant or unnecessary information for the completion of claim forms for school, sports, or extracurricular
activities there may be an administrative fee, not to exceed $35.00, for the additional information.
Your appointment is a reservation of our attention, time and preparation that begins long before you arrive at our
office. We respect and value your time. We require notice of cancellations 48 hours in advance. This allows ample
time for us to offer the appointment to another patient in need of our services. If you fail to keep your
appointments without notifying us in advance: a missed appointment fee may apply. These fees are typically $75.00
but not to exceed one-half of the cost of your scheduled appointment.
Medical Records Fees
Patients are entitled under federal law to have access to their protected health information and we follow all
rules, guidelines, and exceptions to ensure compliance to patient rights. However, providers also have the right to
compensation for records and our fees are a reasonable cost-based fee for copies including the copying, supplies,
labor, and postage of the files, and or summaries.
Timeliness of Appointments
As indicated previously, we place a great deal of effort into pre-planning your appointment needs and estimated time
allotment. We strive to run on time. We expect our patients to extend the same courtesy by arriving on time.
I have read and understand the above financial policy. I agree to assign insurance benefits to the Office of David M. Seidman, DDS whenever applicable.
I also agree, in addition to the amount owed, I also will be responsible for the fee charged by the collection agency for costs of collections if such action becomes necessary.