Thank you for choosing Chips Dental Associates, LLC. Our primary mission is to deliver the best and most comprehensive dental care available. An important part of the mission is making the cost of optimal care as easy and manageable for our patients as possible by offering several payment options.
Payment Options: You can choose from:
- Cash, Check, Visa, MasterCard, American Express or Discover Card We offer a 5% courtesy accounting adjustment to patients who pay for their treatment with cash or check prior to completion of care for treatment plans of $500 or more.
- Convenient Monthly Payment Options (subject to credit approval) from CareCredit or the Healthcare Credit Card. This allows you to pay over time with no annual fees or pre-payment penalties.
Please note: Chips Dental Associates, LLC requires payment prior to the completion of your treatment. If you choose to discontinue care before treatment is complete, your refund will be determined upon review of your case.
A 50% deposit is required to secure your initial treatment appointment.
For patients with dental insurance, we are happy to work with your carrier to maximize your benefit and directly bill them for reimbursement for your treatment. However, If we do not receive payment from your Insurance carrier within 60 days, you will be responsible for payment of your treatment fees and collection of your benefits directly from your Insurance carrier.
A fee of $75 is charged for patients who miss or cancel more than 1 time in a calendar year without 48-hour notice.
Chips Dental Associates, LLC charges $30 for returned checks.
If you have any questions, please do not hesitate to ask. We are here to help you get the dentistry you want or need.
I, the undersigned, certify that I (or my dependent) have the insurance coverage indicated on this form and assign directly to Chips Dental Associates, LLC, all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurances. I hereby authorize the doctor to release all information necessary to secure the payments of benefits. I authorize the use of this signature on all insurance submissions. I consent to the diagnostic procedures and treatment by the dentist necessary for proper dental care. I understand that the information I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status.