Brookdale Dental GroupAnthony G. DeVincentis, D.M.D. Vincent P. DeVincentis, D.M.D.

1218 Broad Street Bloomfield, NJ 07003

Insurance/Financial Overview

Any insurance quote received from Brookdale Dental Group is only an estimate, not a guarantee of payment. As the insured, you are responsible for understanding your insurance policy. Brookdale Dental Group participates with Cigna DPPO insurance. We are “out of network” with all other insurance carriers.

I__________________________________ acknowledge the above and agree that it is my responsibility for the full cost oftreatment whether or not reimbursement is granted by my insurance company.

Patient Name ________________________________________________Date_____________ (Print)

Patient /Responsible Party _____________________________________Date_____________ (Signature)