Asmath Noor, DDS, MDS

Norwalk Village Dental Center- 11274 E, Firestone Blvd, Norwalk, CA 90650



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We are committed to provide you with the best possible care. Our practice depends upon reimbursement from our patients for the costs incurred for their care. If you have dental insurance, we are anxious to help you receive your maximum allowable benefits. In order to achieve these goals we need your assistance and your understanding of our payment policy.

Payment for services is due at the time services are given (including insurance person's portion) unless payment arrangements have been approved in advance by our business staff. For your convenience, we accept cash, checks, and MasterCard or Visa card. We are happy to help you process your insurance claims forms at no additional cost and will accept assignment of insurance benefits; however, we must have your completed insurance form and a provider benefit booklet at your first visit.

Balances older than 60 days regardless of insurance benefits and returned checks will be subject an interest charge of 1.1/2% per month unless prior arrangements have been made. We will gladly discuss your proposed treatment and answer any question relating to your insurance. We ask your understanding that;

  1. Your insurance is a contract between you, your employer, and the insurance company. We are not a party to that contract.
  2. Insurance companies determine their acceptable rate at a percentage (such as 50%, 80% etc) of the average fees charged by dental offices in a zip code (this statement does not apply to companied who reimburse based on an arbitrary "schedule" of fees, which bears on relationship to the current standard and cost of care in this area). Therefore, UCR, which means usual customary and reasonable is never the average rate charged by dental offices in that area.
  3. Not all services are covered benefit in all contracts. Some insurance companies arbitrarily select certain services they will not cover with your benefit booklet. We can help you determine your benefits.

We must emphasize that as dental care providers our relationship is with you not your insurance company while the filing of insurance claims is a courtesy that we extend to our patients and all charges are your responsibility from the services that are rendered. We realize that temporary financial problems may affect timely payment of your account. If such a problem should arise, we ask you contact us immediately. If you have any questions about the above information or any uncertainty regarding insurance coverage PLEASE do not hesitate to ask us. We are here to help you.

I understand and agree that (regardless of my insurance status), I am ultimately responsible for the balance on my account for any professional services rendered. I have read all the above information and understand and agree to the content.

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