Nutrition Services Financial Policy Agreement

Patient Information

Name: _____________________________ Date of Birth: ____________ Address: ___________________________ Phone: _________________

Financial Agreement Terms

1. Payment Responsibility

• I understand that I am financially responsible for all charges, whether covered by my insurance or not
• Payment is expected at the time of service unless prior arrangements have been made
• Co-payments and deductibles are due at the time of service

2. Insurance Coverage

• I understand that while the practice may participate with my insurance carrier, I am responsible for:
  • Verifying my nutrition benefits prior to my first visit
  • Obtaining necessary referrals/authorizations
  • Payment of any non-covered services
• Insurance claims will be submitted on my behalf when applicable

3. Payment Terms

• Accepted payment methods include: credit card, debit card, cash, or check
• Returned checks will incur a $35.00 fee
• Outstanding balances over 90 days may be referred to collections

4. Cancellation Policy

• 24-hour notice is required for appointment cancellations
• Late cancellations or no-shows will be charged a $50.00 fee
• Repeated no-shows may result in discharge from care

5. Package Services

• Prepaid nutrition packages are non-refundable
• Unused sessions expire after 12 months from purchase date

Acknowledgment

I have read and understand this financial policy. I agree to comply with these terms and accept financial responsibility for services rendered.

Patient/Guardian Signature: ______________________ Date: ________

Print Name: ____________________________ Relationship to Patient: ____________