Thank you for choosing our services for your needs. Please read and sign the agreement below. It lays out billing, scheduling and cancellation procedures. If you have any questions please ask for clarification.

Payment of all fees is expected at the time of service or via credit card on file. We will assist you in submitting claims to your insurance carrier.

It is the client’s responsibility to check insurance benefits and coverage. You will be responsible for any non-covered services, deductibles, co-payments or co-insurances, as determined by your insurance carrier. Accounts unpaid by the insurance carrier greater than 90 days will be billed to the client.

I hereby authorize payment of medical benefits directly to (YOUR PRACTICE NAME) for all services rendered where applicable.

Out-of-pocket payments can be made via credit/debit card, cash or check and are due on the date of your appointment. Credit/debit card payments can be made directly with your Registered Dietitian. Please make checks payable to (YOUR PRACTICE NAME). There is a $35 fee for all returned checks.

I hereby authorize (YOUR PRACTICE NAME) to release to government agencies, insurance carriers and all others who are financially liable for my care, all information to substantiate payments for my care and to permit representatives thereof to examine and make copies of all records related to such care and treatment. I understand that if at any point my insurance coverage changes, I am to notify administrative staff prior to my next visit. Failure to do so will result in being personally and completely responsible for the full amount of all services.

I will be responsible to pay a $50 late cancel fee for any missed or cancelled initial visits, not made at least 24 hours in advance prior to the scheduled appointment time.

If I default on my account, I understand I will be subject to finance and/or legal fees in addition to the total account balance.

I, agree to the above financial and cancellation policies. In the case of default payment, I am responsible for full payment of the balance, interest accrued, and any collection costs and legal fees incurred to collect on this account. I understand the scope and limitations of my insurance coverage and agree to pay all fees not covered by my insurance plan. I have read, understand, and accept the information and conditions specified in this agreement