I authorize my dentist and/or administrative staff to use the following protected health information, and/or disclose the following protected health information to my insurance company and/or other physician upon request.
Per national standards to protect the privacy of personal health information, we will only release information requested. This pertains to specific dates of service(s), specific laboratory and /or biopsy results. Medical records will not be released to any entity unless authorized by patient or legal guardian.
This authorization shall be in force and effect until the individual in question no longer requires our services for treatment at which time this authorization to use or disclose this protected health information expires.
I understand that information used or disclosed pursuant to this authorization may be disclosed by the receipt and may no longer be protected by federal or state law.
By utilizing our services or replying to our emails, you acknowledge that you are aware that email is not a secure method of communication, and that you agree to the risks. If you would prefer not to exchange personal health information via email, please notify us by calling (718)285-3035 EXT 2
Financial and Cancellation Policy
Thank you for choosing Leaf Dental! Our goal is to provide you with the most caring and thoughtful dental service available. A part of this making the cost as manageable as possible for our patients.
We must emphasize that as a healthcare provider, the doctor’s relationship is with you, not your insurance company. Our office prides itself on providing the highest quality care and using the best materials available. Our treatment recommendations are based on your individual condition and not on insurance coverage or benefits. While the filing of insurance claims is a courtesy we extend to our patients, all charges are your responsibility for the date of services that are rendered.
Patient insurance policy language clearly states that a verification of benefits is not a guarantee of payment. This means that even if we obtain eligibility before treatment begins and your insurance company denies or reduces benefits, you may be financially responsible for fees. If you will not assume financial responsibility for your treatment, you must let the team know before you are seen by the doctor.
Timeliness is required. We make our best effort to see you on time and get you out on time unless there is an emergency. We do not overbook our doctor’s appointment. We request that you be on time for your visits. If you are late, you may have to reschedule your appointment.
A non-refundable fee of $50 is charged to patients who cancel or change their appointment with less than 24 business hours advanced notice. This is necessary to offset the costs associated with staffing, sterilization and equipment related expenses. An additional fee of $75 is charged to patients who cancel or miss any appointment more than 2 times in a 12 month period. We are permitted to charge and collect these fees and they are not covered by insurance.
You may choose from:
Cash, Check, Apple Pay, Visa, MasterCard, Discover Card, American Express, Health Saving Account (HSA), and Flexible Spending.
Special financing options may apply! Please contact our office staff to learn about the Care Credit program.