DR. NLGD LLC Healthcare Practice
1660 South Alma School Road ▪ Suite 125
Mesa, AZ 85210
P 480.669.6452 ▪ F 888.977.3601
LEGAL - PRIVACY l COPYRIGHT © 2017 - 2018 l DR. NLGD LLC. ALL RIGHTS RESERVED.
Welcome to DR. NLGD LLC Healthcare Practice!
We are honored that you have chosen us as your healthcare provider. Our goal is to
provide the highest quality care for all of our patients in a timely and respectful manner.
Below you will find the required forms to be completed prior to your initial visit.
Download and Complete the Required Forms Prior to Office Visit
These documents can be accessed by clicking FORMS under the PATIENTS tab.
NEW PATIENT INFORMATION
Remember to bring the following to your first appointment:
▪ Your insurance card (if applicable)
▪ Your driver's license
▪ Payment for service is due at the time of service unless payment arrangements
have been approved in advance by our practice manager. We accept credit cards,
checks, cash and money orders. We are happy to process your insurance claim,
and it is your responsibility to provide us with full and accurate information at the time
▪ Our relationship is with you and not your insurance company. Co-pays are due at
the time of service. For your convenience, your co-pay can be paid prior to your
arrival by utilizing the Online Bill Pay.
▪ Please be aware that some insurance companies will pay a claim percentage based on the “usual and customary”
not on your actual charges. The difference between what we bill and what they pay is your responsibility.
▪ Private pay accounts are expected to pay at the time of service. Pre-arrangements may be made with my practice manager prior to the appointment. Patients may be dismissed from the practice for failure to follow the financial
agreement. Please refer to the Membership Services Guide located on the FORMS page
▪ Delinquent accounts will be referred to a collection agency at our discretion. If our collection agency or if we take
any legal action, the non-prevailing party agrees to pay the legal costs.
▪ A $25.00 fee will be charged for repetitive (3 or more) appointments missed without notice. Please refer to
the Medical Appointment Cancellation Policy on the FORMS page.
CLICK THE REQUESTED NEW PATIENT FORMS BELOW:
Healthcare Practice 'Providing High Quality Cost-Effective Healthcare To All'