New Patient Packet Information

We participate with most insurance plans, including but not limited to; Aetna Dental PPO; Ameritas; Blue Shield Blue Cross; Cigna; Companion Life; Delta Dental Premier Provider; GEHA; Guardian; Met Life Dental; Principal; Financial Group; Priority Health; United Concordia; United Healthcare

To Our Appreciated Patient,

It is our desire to constantly improve services and quality of care for you so that you can regain and maintain your dental health as quickly, efficiently and inexpensively as possible. Our policy is to make your experience in our office an exceptional one. When we succeed, we would appreciate you telling your family and friends about our office. Therefore, the following must be agreed upon:

1. Insurance: Treatment recommendations are based on your health not on your insurance or lack thereof. If you have insurance it is your responsibility to be aware of what your benefits are. Remember insurance companies are not concerned about your health or wellbeing-we are. As a courtesy, we will provide you with an estimate of benefits; however you are fully responsible for any treatment performed. Your benefits are a contract between you and your insurance company. As a reminder, we cannot be responsible for what your insurance will or will not cover.

2. Timeliness is required. We will see you on time and get you out on time unless there is an unforeseen emergency. We request that you be on time for your visits. If you are more than 10 minutes late, you may have to reschedule your appointment. Cleanliness and infection control are of the utmost importance. We have the latest sterilization technology and disinfect each treatment room after every patient. This is an important reason why we demand timeliness of you and ourselves.

3. If you miss an appointment, it is critical to your health to make it up so to avoid setbacks in the care and maintenance of your teeth and gums. Failure to make an appointment not only compromises your health but it also inconveniences other patients who may have requested an office visit during your reserved appointment. If you cannot make an appointment (except in the case of an emergency) you are expected to give us notice 48 hours before the appointment to reschedule. There is a $100 fee for all no-show and cancelled appointments w/o 48 hour notice. This fee is not covered by insurance.

4. We strive to run a Zero Balance office. In order to achieve this we require 50% of your total patient out of pocket expense to reserve any scheduled appointment. We have several financial options available for all of our patients. Please speak with Lee if you have any questions regarding financial options.

5. Emergencies: It is our goal to eliminate all of the potential dental emergencies that you may have by providing care for you before it becomes a problem. In the rare instance that you do have an emergency we want you to be assured that we will take care of you. We define a true emergency as swelling, bleeding, severe pain that has kept you up at night or requires medication or a restoration in a visible area that falls out. If you experience any of these conditions, we ask that you call us right away. We will provide you with the next available emergency appointment. We set aside time daily for emergencies.

We expect these attached forms to be printed and filled out at arrival time of scheduled appointment.

Thank you! The Team at David S. Novak D.D.S.

Financial Policy Form (Download PDF)

We are committed to providing you with the best possible dental care. If you have special needs, we are here to work with you. The following information is provided to avoid any misunderstanding or disagreement concerning payment for dental services.

HIPAA Privacy Act (Download PDF)

ADA Health History(Download PDF)

Smile Evaluation Form(Download PDF)