Nicholas C. DeRobertis, DMD LLC

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Nicholas C. DeRobertis, DMD LLC Esthetic, DRestorative & Implant Dentistry 354 Old Hook Road, Suite 202 Westwood, NJ 07675 201-666-2125 1 FINANCIAL POLICY NARRATIVE & AGREEMENT I. INTRODUCTION: Thank you for choosing us to provide you with the latest in total oral care. We consider it an honor to have been chosen by you to do so. Our philosophy in serving people is to be informative, honest and always appreciative of an open dialog for discussion. Nowhere is this more important than in the area of finances; this Financial Policy Narrative & Agreement contains many particulars in this regard. It is also indicative of our respect for your right to know ahead of time all of the expectations in finances and dental insurance we require. There is much to read and comprehend; we only ask that you understand our rationale for illustrating these concepts to you in this manner. Many items contained here have been refined after over 22 years of experience in dealing with 3rd party payors. Although it may seem confusing to you, especially if no one has ever taken the time or effort to alert you of the idiosyncrasies of dental insurance, we hope this information will help clarify a very nebulous part of a modern dental practice. Please read this in its entirety and sign where indicated. Of course, we will be here to answer any questions you may have or help review it with you. You can rest assured that your personal health information is safe. Our office protects all of your valuable personal information and is in strict compliance with the latest HIPAA regulations. II. DENTAL INSURANCE: As a courtesy to our family of patients, we will gladly file your dental insurance claims and accept assignment of insurance benefits (for those insurance plans in which we are preferred providers) as long as you agree to the following: 1. You must provide us with a valid insurance card and all the information necessary to verify your insurance coverage, including the social security number and date of birth of the subscriber of your particular plan. 2. In the case of dependent children who are enrolled in full-time colleges, we also require a copy of the childʼs school ID card that is valid during the time of dental treatment. a) We WILL NOT PROCESS insurance claims without this document. b) If this document is not present at the time of treatment, the treatment rendered MUST be paid at the time of service and any claims submitted will be the responsibility of the parent/guardian. 3. Your insurance policy is a contract between you, your employer and the insurance company. We are NOT a party to that contract. Your benefits package contains the type of insurance benefits your employer has chosen to give you. Our relationship is with you, not your insurance company. 4. Fees we submit for reimbursement are the fees our office charges for the various procedures we perform. Many times, these fees are different from those on your insurance company schedule of allowances. They will, in turn, adjust these fees according to the benefit package your employer has chosen for your coverage. As a preferred provider, we will adjust our fees as well and your responsibility is this adjusted fee. Please remember that there is a difference in coverage allowance between insurance companies as well as within the same insurance company. Your schedule of benefits and allowances is based on the benefits package your employer has chosen for you. 5. All of your coverage information is contained in your insurance handbook. We strongly suggest you read your handbook and familiarize yourself with it. If you have not received one, you should contact your Human Resources manager at your place of employment and request one.

2 6. Although we may estimate your insurance benefits based on information we receive from your carrier via FAX, e-mail, web or telephone conversation, we are not responsible for its accuracy. If your carrier provides us with inaccurate or erroneous information, you are ultimately responsible for any fees for treatment rendered. 7. Please remember that you are responsible to know your schedule of benefits, as well as benefit amounts, limitations, exclusions, waiting periods, etc. Receiving our services indicates your acceptance of responsibility to pay regardless of our estimate. 8. We will provide your insurance carrier all the necessary information to process your claims in an expedient manner. 9. Do you know the law when filing dental claims? Dental insurance companies have 30 days from the date of receipt of a dental claim to process the claim or to notify the patient and doctor if there will be a delay in processing or payment. If they were NOT to comply, you have the right to contact the State of NJ Department of Banking & Insurance and file a complaint against your carrier. More info can be gleaned at their website: www.nj.gov/dobi 10. Should your carrier delay processing of your claim or per-treatment estimate or fail to provide a timely explanation as to their reason for their delay or nonpayment, it is ultimately your responsibility for payment of these services. 11. This office will not wait more than 30 days to receive payment from your insurance carrier. If there is a delay in this payment, you will be responsible for the total amount we should collect for this treatment and, if payments are ultimately received, they will be forwarded and endorsed to you. In this regard, we will only provide written narratives, letters of appeal or any other information the insurance carrier deems necessary AFTER the entire balance for that claim is paid in full by you. Again, payments received for these claims on zero balance accounts will be forwarded back to you. 12. All covered charges NOT paid by your insurance company are your responsibility, regardless of the reason(s) for nonpayment. 13. Not all treatment we provide falls within your schedule of covered benefits. 14. The treatment recommended and performed is based on your medical necessity for this treatment and not based on the coverage schedule your particular insurance plan will allow. It is important you make the distinction between the trust you have bestowed upon us as your treating physician and the recommendations of a third-party payor, who has NEVER examined you. 15. Insurance companies are for-profit organizations, who are notoriously interested in providing you with the care that is the least costly (to them), yet provides you with treatment that may correct your problem(s). 16. #15 above is most clearly illustrated in the area of tooth-replacements. If you require the replacement of a tooth (or teeth), the best modality for this treatment would be implants or, at the very least, tooth-supported crown and bridge treatment. Unfortunately, insurance companies feel that a removable partial denture will do the very same thing implants or crowns will do, but at a much lesser cost. Insurance companies, however, place the responsibility on the patient, by allocating benefits for the least costly replacement treatment, thereby making the patient responsible for the difference in fees, should they opt for this treatment. 17. Benefits differ from one company to another as well as within the same company. Your benefits are solely dependent on the type plan your employer has chosen for you. 18. Fees for non-covered services, along with yearly plan deductibles and co-payments are due at the time of treatment. 19. Your signature on this form signifies your consent and authorization to the concepts outlined. 20. NO INSURANCE CLAIMS WILL BE PROCESSED UNLESS THIS OFFICE RECEIVES THIS SIGNED FORM FOR EACH PATIENT. III. PAYMENT POLICY: 1. We accept cash, personal checks, debit cards, Visa, MasterCard, American Express and Discover. 2. To avoid finance charges, payment on account balances is expected within 26 days of the statement date.

3 3. If your insurance company does not pay in full within 30 days, it will be your responsibility to pay the outstanding balance. 4. We do not file claims with medical insurance companies, Medicare, Medicaid, DMOʼs or more than one dental insurance carrier per patient. IV. PATIENTS WITHOUT INSURANCE COVERAGE: 1. All fees in this office are identical, irrespective of insurance coverage Therefore, fees incurred by noninsured patients are the same as those with insurance coverage. 2. We provide written estimates of fees. 3. Payment is expected at each visit for treatment rendered. V. MINOR PATIENTS: 1. The parent or guardian of the minor is the guarantor and is responsible for payment. 2. In the case of divorced or separated parents, our office is to be notified in writing of the person(s) responsible for payment. VI. RETURNED CHECK POLICY: 1. A minimum fee of $25,00 will be added to your account when your check is returned by the bank. 2. Any additional bank charges incurred as a result of this returned check will be your responsibility for payment. VII. FINANCE CHARGES AND COLLECTION FEES: 1. Finance charges will be applied to all balances not paid within 25 days of the monthly billing cycle. 2. A late charge of 1.5% on the balance then unpaid and owed will be assessed each month until paid. 3. It is YOUR RESPONSIBILITY to ensure that your insurance company pays promptly so you can avoid finance charges. 4. You are responsible for collection costs and reasonable attorney fees incurred in attempting to collect on this amount or any future outstanding account balances. 5. Correspondence from our office with regard to problems in collection is sent via Certified Mail/Return Receipt. If, for any reason, our correspondence is returned to this office as undeliverable or refused by recipient, account balances are due in full immediately. Please see section below (VIII. Overdue Balances). 6. We understand temporary financial problems may affect timely payment of your balance. If those unfortunate events were to occur, we encourage you to communicate any such problems immediately so we may assist you in the management of your account. VIII. OVERDUE BALANCES: 1. Any account with an unpaid balance past 90 days will be sent to a collection agency. 2. At that time, you will be responsible for any and all costs incurred in the collection of your debt: an interest rate of 21% on the unpaid balance from the last date of service, attorney fees, court fees and any other fees associated with the collection of your debt. IX. BROKEN OR MISSED APPOINTMENTS: 1. Broken appointments prevent others from receiving the dental care they deserve, so please be considerate and inform us in advance if you need to change your appointment. 2. Appointments not kept or changes with less than 24 hours notice are considered broken. Broken appointments will be rescheduled, but will be subject to additional fees. 3. A $75.00 fee will be assessed for every broken appointment and payment is due before treatment is commenced at the rescheduled appointment time. 4. We reserve the right to terminate the professional relationship of any patient when scheduled appointments are not kept.

4 5. All of the above are in effect from the time this form is either sent via regular mail or hand-delivered to the patient or guardian. In cases where initial appointments are not kept, for whatever reason, and prior notice is not given, this constitutes a no-show or broken appointment and, therefore, the missed appointment fee is assessed to the patientʼs financial record. X. AFTER-HOURS EMERGENCY VISIT FEES: 1. In addition to the fee for the treatment provided, a fee of $175.00 will be assessed to your account if treatment is rendered after our normal hours of operation. 2. This fee is your responsibility and NOT SUBJECT to submission to your insurance carrier for payment. 3. This fee is due at time of after-hours emergency treatment. XI. RECORDS: 1. Your records, including radiographs (x-rays) are the property of this office. 2. If you desire, after receiving a written request from you, we will provide you with a copy for a duplication fee of $50.00, plus $0.25/page for photocopying. XII. CONSENT AND AUTHORIZATION: 1. I authorize dental treatment by Dr. DeRobertis or his associates. 2. I agree to pay all related professional fees. 3. Fees not covered by my insurance carrier will be promptly paid once I am notified of any balance from this office. 4. I have read and understood this document in its entirety, outlining office policies and financial policies of Nicholas C. DeRobertis, DMD, LLC. 5. Without any reservations, I agree to abide by the policies outlined herein. Name Signature If minor, relationship to minor Date Are you the person legally responsible for this minor? YES NO If NO, please indicate responsible person(s) Staff member reviewing this document Date

D Nicholas C. DeRobertis, DMD LLC Esthetic, Restorative & Implant Dentistry 354 Old Hook Road, Suite 202 Westwood, NJ 07675 201-666-2125 MEDICAL HISTORY UPDATE VERIFICATION Having previously completed a comprehensive medical/dental history on file with Dr. DeRobertis, my reason for treatment today is any one of the following o To continue with dental treatment o Periodic periodontal maintenance o Limited oral evaluation-problem focused emergency treatment. The following are changes to my history and/or medication regimen as prescribed by my treating physician: Please check this box, if there has been NO CHANGE to your medical history or medication regimen. Please check this box, if you have taken your prescribed pre-treatment antibiotics for SBE prophylaxis. Patient Signature & Date

Nicholas C. D DeRobertis, DMD LLC 354 Old Hook Road, Suite 202 Westwood, NJ 07675 201.666.2125 I N F E C T I O N C O N T R O L We take great pride in providing our family of patients with the latest protocols to ensure their safety in the dental office setting. Our infection control procedures strictly adhere to those guidelines recommended by The Center for Disease Control (CDC) and The Occupational Safety and Hazard Administration (OSHA). We utilize the proper personal protective equipment; barrier protection; instrument processing and sterilization and patient education, so that we can be assured that our patients (and our staff) are well-guarded against the potential transmission of infectious agents. We utilize latex-free disposables as much as possible. Latex-free also eliminates any potential latex-induced allergic reactions. Anything that is NOT disposable is STERILIZED. Autoclave sterilization occurs after biofilm is removed via ultrasonic cleaning in an antimicrobial solution. Handpieces (drills) are also sterilized, however they are put through a pre-sterilization cleaning protocol in which they are mechanically purged with disinfecting solution and lubricant. Although pre-treatment mouth rinses with antimicrobials (like Listerine) significantly reduce the amount of oral microflora, another method of reducing the numbers of harmful organisms in the dental office setting is to refrain from elective procedures when patients are battling an infection that can spread microorganisms through aerosol formation. Therefore, it is also part of our infection control policy to not perform elective treatment on patients who are battling any type of communicable infections like measles, chicken pox, strep-throat or other conditions resembling an upper respiratory infection, the common cold, influenza, recurrent herpes labialis, or any other condition in which the airborne spread (or direct contact) of microorganisms can pose a potential risk to other patients or staff. Therefore, it is mandatory that our patients adequately advise us if they are suffering from any of these temporary conditions so we can alter their appointments until after they have recovered from these maladies. Dr. DeRobertis is also a member of OSAP, The Organization for Safety and Asepsis Procedures. OSAP is a unique group of dental practitioners, allied healthcare workers, industry representatives, and other interested persons with a collective mission to promote infection control and related science-based health and safety policies and practices. OSAP supports this commitment to the dental workers and the public through quality education and information dissemination. 1 If you have any questions, would like us to review our infection control procedures or care to have a tour of our infection control and sterilization procedures, we would welcome this opportunity to share our commitment to safety with you. Also, we urge you to visit the OSAP website so you can become more aware of the scope of this very crucial specialty. 1 From www.osap.org

Nicholas DeRobertis,DMD 354 Old Hook Road, Suite 202, Westwood, NJ 07675 201-666-2125 NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US. OUR LEGAL DUTY We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect (08/14/2004), and will remain in effect until we replace it. We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request. You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice. USES AND DISCLOSURES OF HEALTH INFORMATION We use and disclose health information about you for treatment, payment, and healthcare operations. For example: Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you. Payment: We may use and disclose your health information to obtain payment for services we provide to you. Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities. Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice. To Your Family and Friends: We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so. Persons Involved In Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person s involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information. Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization. Required by Law: We may use or disclose your health information when we are required to do so by law. Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others. National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement official having lawful custody of protected health information of inmate or patient under certain circumstances. Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters). PATIENT RIGHTS Access: You have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. (You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact

information listed at the end of this Notice. We will charge you a reasonable cost-based fee for expenses such as copies and staff time. You may also request access by sending us a letter to the address at the end of this Notice. If you request copies, we will charge you $0. for each page, $ per hour for staff time to locate and copy your health information, and postage if you want the copies mailed to you. If you request an alternative format, we will charge a cost-based fee for providing your health information in that format. If you prefer, we will prepare a summary or an explanation of your health information for a fee. Contact us using the information listed at the end of this Notice for a full explanation of our fee structure.) Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations and certain other activities, for the last 6 years, but not before April 14, 2003. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, costbased fee for responding to these additional requests. Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency). Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. {You must make your request in writing.} Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request. Amendment: You have the right to request that we amend your health information. (Your request must be in writing, and it must explain why the information should be amended.) We may deny your request under certain circumstances. Electronic Notice: If you receive this Notice on our Web site or by electronic mail (e-mail), you are entitled to receive this Notice in written form. QUESTIONS AND COMPLAINTS If you want more information about our privacy practices or have questions or concerns, please contact us. If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request. We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services. Contact Officer: Rose Musto Telephone: 201-666-2125 Fax: 201-666-9576 E-mail: Address: 354 Old Hook Rd Westwood, NJ 07675 2002 American Dental Association All Rights Reserved Reproduction and use of this form by dentists and their staff is permitted. Any other use, duplication or distribution of this form by any other party requires the prior written approval of the American Dental Association. This Form is educational only, does not constitute legal advice, and covers only federal, not state, law (August 14, 2002).

Nicholas DeRobertis, DMD 354 Old Hook Road, Suite 202 Westwood, NJ 07675 ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES **You May Refuse to Sign This Acknowledgement** I,, have received a copy of this office s Notice of Privacy Practices. {Please Print Name} {Signature} {Date} For Office Use Only We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because: Individual refused to sign Communications barriers prohibited obtaining the acknowledgement An emergency situation prevented us from obtaining acknowledgement Other (Please Specify) 2002 American Dental Association All Rights Reserved Reproduction and use of this form by dentists and their staff is permitted. Any other use, duplication or distribution of this form by any other party requires the prior written approval of the American Dental Association. This Form is educational only, does not constitute legal advice, and covers only federal, not state, law (August 14, 2002).

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