Financial Agreement Form

We, the staff of David Seidman, DDS, thank you for choosing us as your dental health provider. We consider it a privilege to serve your needs and we look forward to doing so. We are committed to providing you with the highest level of care and to building a successful provider-patient relationship with you and your family. We believe your understanding of our patients’ financial responsibility is vital to that provider-patient relationship and our goal is not only to inform you of the provisional aspects of that financial policy but also to keep the lines of communication open regarding them. If at any time you have any questions or concerns regarding our fees, policies, or responsibilities please feel free to contact our Financial Coordinator at 212-223-0911.

We believe this level of communication and cooperation will allow us to continue to provide quality service to all our valued patients.

Please understand that payment for services is an important part of the provider-patient relationship. If you do not have insurance, proof of insurance, or participate in a plan that will not honor an assignment of insurance benefits, payment for services will be due at the time of service unless a payment arrangement has been approved in advance by our staff.

We make payment as convenient as possible by accepting (cash, money order, MasterCard, Visa and AmEx. Some in-state checks may be accepted, please speak to our Financial Coordinator. A $35.00 service fee will be charged for all returned checks. Additionally, you may authorize us to keep your credit card on file for your convenience knowing that we adhere to the highest level of information security.


Interest will incur if a balance remains unpaid after 60 days. Insurance companies typically settle transactions within 30 day, by laws.


Please remember that your insurance policy is a contract between you and your insurance carrier. We will, as a courtesy, bill your insurance and help you receive the maximum allowable benefit under your policy. We have found that patients who are involved with their claims process are more successful at receiving prompt and accurate payment services from their insurance carrier. We do expect patients to be interactive and responsible for communicating with your insurance carrier on any open claims.

Dental Insurance Fundamentals

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.

Missed Appointments

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.


Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.