Office Policies / Patient Forms

Insurance Policies

Our administrative staff will be glad to assist you with any insurance concerns.  Our office has the ability to electronically submit your insurance claims at the time of service.  Your copayment will be required at the time services are rendered.

Some insurance companies offer employer's many different types of dental plans. All managed care plans will  pay only a percentage of the plan fees whether you are in or out-of-network. These percentages are determined by your employer when picking the plan. The insurance companies can also change your benefits, copays and deductibles throughout the year so it is important that all information about you and your insurance company is kept current.

We will call your insurance carrier to obtain your benefits. Please provide us with the name of your insurance company, identification number and group number so that we may obtain this information.  Please call us to discuss your particular dental insurance plan and how we may help you.

Cancellation Policy

We make every effort to be on time for our patients, and ask that you extend the same courtesy to us. If you cannot keep an appointment, please give us at least 48 hours notice. This courtesy on your part will make it possible for us to give the appointment to another patient who needs to be seen. We understand that situations may arise that would make it impossible for you to give 48 hour notice and each incident will be given consideration based upon your appointment history. Missed or broken appointments without notice may be charged to the patient account.

Patient Forms

For your protection and privacy, we prefer that forms be brought to the office for your appointment, not submitted online. Please click on the links below to print the following forms, which you can submit at the time of your appointment:

Patient Information Form

Patient Medical History Form

Authorization to Transfer Records

Dr. Brzozowski's HIPPA Policy Form

Dr. Tepel's HIPPA Policy Form

New Patients: We would like to welcome you to our office.  Please complete the patient information, patient medical history and HIPPA forms.  If you would like records from your previous dentist transfered to our office please complete the authorization to transfer records form.