Request Appointment

PATIENT FORMS – Part 2

Thank you for filling out our patient forms

Please take a few minutes to fill out this final form as completely as you can. If you have any questions, we’ll be glad to help you. We look forward to working with you in maintaining your dental health.

1 FInancial Services Guide
2 Informed Consent For Opioid Use
  • FINANCIAL SERVICES GUIDE

  • PLEASE REMEMBER YOU ARE RESPONSIBLE FOR UNDERSTANDING YOUR COVERAGE. If your insurance plan and or coverage changes, it is your responsibility to notify us. We cannot be responsible for charges that are denied because we have relied on information that is not current. In this event you are responsible for your bill.
  • We work with most insurance companies but we may not participate with your plan. This does not mean you cannot be treated at our office, it just means that your estimated co-payment will be due at the time of visit and we will bill your insurance company for the balance. Some of the services that you receive may be deemed "not covered" under your policy, as not all insurances cover what is needed. Although we will assist you in obtaining the information, if needed, you are responsible for understanding the payment policies, guidelines and limitations of your insurance plan. We will help you clarify your coverage when you inform us of changes. If you receive a non-covered service, your payment will be due at that visit.
  • Our Billing and Collection Process

  • Payment is due upon your receipt of a statement. If you fail to make payment of your balance by the end of 30 calendar days, you may be charged an additional monthly administrative fee. This fee will be cumulative each month until your balance is paid in full. For your convenience, we will accept cash, checks, American Express, Discover, MasterCard and Visa as forms of payment.
  • If Your Account Becomes Delinquent

  • Should your account become delinquent 45 days, you will receive a phone call or letter. If you do not respond to discuss your balance we may refer your account to an outside agency. You should also be aware that a referral of your balance to a collection agency may constitute grounds for your discharge as a patient.
  • Our Cancellation and No Show Policy

  • The time we set aside for your appointment is important and affects our efforts to efficiently serve all of our patients. If you are unable to keep your appointment you must provide us with at least 24 hours notice of the scheduled appointment. Should you not give sufficient notice or do not show for your appointment a $50.00 cancellation fee may apply.
  • Type your name to sign electronically
  • Today's Date: 12/12/2019

Been a patient for almost 20 years, staff is always friendly and helpful. Dr Roman is great, he listens to his patients and makes you feel like a priority. Definitely recommend. You will not be disappointed.

Margaret Lee
READ MORE

Roman Dental Arts Is Easy To Find!

For main entrance and parking,
enter at 180 Grand Ave, Hackensack NJ

FIVE STAR DENTISTRY IN YOUR NEIGHBORHOOD

Roman Dental Arts in Hackensack, NJ is committed to providing exceptional state-of-the-art dentistry. Our patients appreciate the comfortable experience and modern technology they receive from our friendly and caring team.

While our patients travel from many locations, here are some of the communities within Bergen County we serve. New patients are always welcomed into our dental family.

  • Hackensack

  • River Edge

  • Maywood

  • Paramus

  • Oradell

  • Rochelle Park

  • Teaneck

  • New Milford

  • Bergenfield

  • Dumont

  • Saddle Brook

  • Hasbrouck Heights