FORM AND INSTRUCTION FOR PATIENTS:

FOR OFFICE USE ONLY : ORAL SURGERY FORMS

- Welcome Advanced Dental Orthodontic

- Informed Consent Orthodontics Patient - Advanced Dental

- Release of Liability Early Removal of Orthodontic Appliances

- Informed Consent Braces Removal and Retainer Consent Form

- Transfer Patient in-Active Treatment ortho.pdf

- Healthplex Orthodontic HLD Form

- Denta Quest Orthodontic HLD Form

- Ortho Tx form START/BONDING

- Payment arrangement 12 months comprehensive orthodontic treatment

- Payment arrangement 24 months comprehensive orthodontic treatment

- Payment arrangement orthodontic treatment government.pdf

- Payment consent Delta Dental/32BJ ortho 2018.pdf

- Payment consent Healthplex Local 237/Local100 ortho.pdf

- Payment consent GHI ortho 2018.pdf

FOR OFFICE USE ONLY:ORAL SURGERY FORMS

- Welcome package Oral Surgery Procedures

- Welcome Oral Surgery CONSULTATION

- Welcome Oral Surgery Scarsdale

- Advanced Dental Surgery "Tx" Form

- Informed Consent Form for Oral and Maxillofacial Surgery and Anesthesia

- Implant Consent Form

- General Anesthesia Record

- Discharge Sheet

FOR OFFICE USE ONLY : ENDO FORMS

- Informed Consent for Endodontic Treatment

- Dentist/Doctor Exuse Letter

- Disclosure sheet for cosmetic or uncovered treatment

FOR OFFICE USE ONLY:OTHER FORMS

- Financial Policy Advanced Dental 2018

- Advanced Dental "M" Form

- Advanced Dental "I" Form

- Notice of privacy practices Advanced Dental

- Dentist/Doctor Exuse Letter

- Disclosure sheet for cosmetic or uncovered treatment

- Advanced dental worksheet

FOR OFFICE USE ONLY: INFORMED CONSENT FORM

- Informed Consent Form nitrous oxide sedation

- Informed Consent Form Filling

- Informed Consent Form crown and bridge prosthetics

- Informed Consent Braces Removal and Retainer Consent Form

- Release of Liability Early Removal of Orthodontic Appliances

- Disclosure sheet for cosmetic or uncovered treatment

- Aetna dental PPO plans fee schedule.pdf

- Denta Quest Emblem | Child medicaid | Child health plus (CHP) |Essential plans | Medicare advantage |Exchange QHP

- Denta Quest healthfirst hfic

- Denta Quest Fidelis Exchange | Affinity Exchange | Healthfirst Exchange

- DC37 fee schedule for ortho, pedo, endo 2018.pdf

-Liberty dental plan New York Medicaid CHIP.pdf

- UFT dental fee schedule.pdf

     

INSURANCE PHONE NUMBERS

Denta Quest	800-341-8478	https://govservices.dentaquest.com
Denta Quest HIP		https://provider.dentaquest.com/providerlogin
Healthplex	888-468-2183 Fax: 516-542-2614	https://healthplex.com/provider
HIP Carrington	800-477-8255
Liberty Dental Plan	888-352-7924	www.libertydentalplan.com
Medicaid	800-343-9000	https://www.emedny.org/epaces/Login.aspx
AETNA	800-451-7715	https://www.aetna.com/provweb/index.html
BCBS	800-722-8879
BCBS federal	800-522-5566
Cigna	800-342-5234	https://cignaforhcp.cigna.com
Daniel H Cook	(212) 505-5050 Fax: (212) 7141455	https://www.dhclaims.com
DC37	212-815-1600	https://www.inmediata.com/us/index.php
Delta Dental	800-932-0783	https://www.deltadentalins.com
DeltaDental Mass	617-886-1234
Delta Dental Virginia	800-237-6060
DDS (MagnaCare)	800-255-5681
Dental Shop	888-683-3682
Guardian	800-541-7846	https://www.guardiananytime.com
GHI Emblem Health (1199)	646-473-7160 212-501-4444	https://www.emblemhealth.com
Local 371	212-777-9000 (ext. 3069, 3059, 3070) Fax: 212-260-7908
Local 1180	212-505-5050
Loclal 94 (Seledent)	800-520-3368
MetLife	800-275-4638	https://www.metdental.com/prov/execute/home
PBA	212-349-7560
United Concordia		https://www.unitedconcordia.com
Seledent	516-887-7566
SIDS	718-204-7172	https://www.asonet.com/dentist.aspx
UFT	800-577-0576
United Health Care (Community plan)		https://pwp.sciondental.com/PWP/Landing
UHC	877-816-3596

To schedule an appointment with Oral surgeon please contact Advanced Scarsdale Oral Surgery:

P:(914) 874-5757
130 Garth Road
Scarsdale, NY 10583

Monday-Saturday

WE ARE OPEN SATURDAYS
Meet Your Oral Surgeon