Please fill out the following forms and fax them to our office for your convenience.

Financial Agreement Form


Protecting Your Health Information Form


Patient Information Form



  • 1199SEIU
    • National Benefit Fund (All locations)
  • Aetna
    • Dental PPO/PDN (All locations)
  • Aflac
    • Aflac Dental (All locations)
  • Blue Cross Blue Shield
    • BlueCard® PPO/EPO (All locations)
  • Cigna
    • Cigna Dental EPO: Core Network (All locations)
    • Cigna Dental EPO: Radius Network (All locations)
    • CIGNA Dental PPO (All locations)
    • Cigna Dental PPO: Core Network (All locations)
    • Cigna Dental PPO: Radius Network (All locations)
    • United Federation of Teachers (UFT) (All locations)
  • Delta Dental
    • Delta Dental PPO (All locations)
    • Delta Dental PPO Plus Premier (All locations)
    • Delta Dental Premier (All locations)
    • MAC (Maximum Allowable Charge) a feature of Delta Dental PPO (All locations)
  • EmblemHealth
    • Dental Preferred (All locations)
    • Dental Preferred Plus (All locations)
    • Federal Employees Dental (FEDVIP) (All locations)
  • Empire Blue Cross Blue Shield
    • Dental Complete (All locations)
    • PPO (All locations)
  • GHI
    • Preferred Plus (All locations)
  • Guardian
    • DentalGuard Alliance / DentalGuard Preferred (All locations)
    • DentalGuard Preferred Select (All locations)
  • Healthplex
    • Healthplex PPO (All locations)
    • PPO Panels: Capital Plus Panel (All locations)
  • MetLife
    • Federal Dental (FEDVIP) (All locations)
    • PDP (All locations)
    • PDP Plus (Preferred Dentist Program) (All locations)
  • Premier Access
    • Dental PPO (All locations)
    • Healthy Kids Santa Barbara (All locations)
    • Los Angeles Pre-Paid Health Plan (All locations)
    • Utah Children’s Health Insurance Program (UT CHIP) (All locations)
  • Principal Financial Group
    • Principal Plan PPO (All locations)
  • Sele-Dent
    • NY/NJ Sele-Dent Provider (All locations)
  • Union Plans
    • 1199 SEIU (All locations)
    • NYC Retirees Welfare Fund (All locations)
    • Patrolmen’s Benevolent Association (All locations)
    • Patrolmen’s Benevolent Association PPO (All locations)
    • Rockville Centre Teachers Association (All locations)
    • Roslyn Teachers Assoc Benefit Fund (All locations)
    • Sanitation Officers Retiree (All locations)
    • Social Service Employees Union Local 371 (All locations)
  • UnitedHealthcare
    • Dental PPO (All locations)
    • Dental Premier (All locations)
    • Dental Value (All locations)
    • Government Employees Voluntary Benefits Trust (All locations)
    • National Options PPO 20 (All locations)
    • National Options PPO 30 (All locations)
    • PPO National Network (All locations)