Thank you for choosing Michigan Avenue Dentistry. 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.
You can choose from:
Please note, Michigan Avenue Dentistry 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.
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 30 days, you will be responsible for payment of your treatment fees and collection of your benefits directly from your insurance carrier. All co-pays are due at time of treatment.
Our office adheres to the Federal “HIPAA” Health Insurance Portability and Accountability Act. We do not sell your personal or medical information to anyone. We do not share your information with anyone other than your insurance carrier, pharmacist, or other dental specialist. We keep all your information confidential.
I acknowledge that Michigan Avenue Dentistry's Notice of Privacy Practices has been available to me. I understand I have the right to review Michigan Avenue Dentistry's Notice of Privacy Practices prior to signing this document.
The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that will occur in my treatment, payment of my bills, or in the performance of healthcare operations at Michigan Avenue Dentistry.
The Notice of Privacy Practices is also provided upon request at the main administration desk of this practice.
This Notice of Privacy Practices also describes my rights and Michigan Avenue Dentistry's duties with respect to my protected health information.
Michigan Avenue Dentistry reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised Notice of Privacy Practices by calling the office and requesting that a revised copy be sent in the mail or by asking for one at the time of my next appointment.
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