Specialty Nutrition and Health, LLC
Consent To Treat and Payment Authorization (rev 07/16/2014)
I understand that I will be receiving treatment/services rendered by practitioners of Specialty Nutrition and Health LLC (SNH). These may include but are not limited to Medical Nutrition Therapy, Nutrition Counseling, Metabolic Rate Testing, Anthropometrical Measurements, Blood Sugar and Blood Pressure tests. I release practitioners at SNH from any liability associated with these treatments.
Payment
Client is responsible for charges for services provided. Co-pays, deductibles and denied/non-covered services are the responsibility of the client. Payment is expected at time of service. Any outstanding account balances 90 days past date of service will be charged a $30 late payment fee. Accounts overdue will be turned over to a collections agency or attorney and client will be responsible for all incurred charges.
In Network Insurance Carriers: Claims will be sent by SNH to the insurance carrier. Client is responsible for obtaining any authorizations/referrals that are needed and to determine coverage of service. SNH does not guarantee any coverage; please check with your Insurance company to verify benefits.
Medicare: Medicare provides coverage for Medical Nutrition Therapy for Diabetes and Renal Disease (non-dialysis). A prescription must be obtained from the treating physician or qualified health care professional each calendar year that services are provided. During the initial referral calendar year, 3 hours of MNT can be approved. Each following year 2 hours of MNT can be approved. If you have received MNT services in the past, this will affect your coverage.
Self-Payment: (This includes out of network insurance carriers) Payment is due at time of service. Package pricing may be available for follow up visits after the initial consult. You will be asked to sign a separate agreement for Treatment Packages.
Privacy Policy
SNH makes every effort to comply with federal guidelines relating to HIPAA. Privacy Policies are available in the office for review and you may request a copy for your records.
Transfer of Information
I give permission for my health information to be shared with SNH. This may include but is not limited to lab results, office notes, insurance information and medication lists.
Cancellation Policy ______(initial)
Please call by 12:00 pm of the preceding business day to cancel or reschedule any appointments. This allows us to schedule other clients who may be waiting for appointment times to become available.
If you cancel your appointment after 12:00 pm of the preceding business day there will be a $50late cancellation fee. These fees are not billable to insurance and must be paid prior to the next appointment.
Please indicate the following:
_____ I have read and understand the above policies of SNH
_____ I have had the chance to review and request a copy of SNH privacy practices.
Medicare Clients: I have ____ have not ____ previously received Medical Nutrition Therapy.
Client Name: ______
Client Signature: ______Date: ______
SNH Representative: ______Date: ______
Advanced Beneficiary Notice:______
______
Rev. 7/16/14