I agree that payment is expected when services are rendered. Provisional credit may be allowed for confirmed insurance benefits assigned to MNT
specialist E. Couchoud-Wilkinson MS, RDN, LD. All such provisional credits are subject to collection.
In-network Provider - NutritionECW.com will file your Insurance only if Mrs. E. Couchoud-Wilkinson MS, RDN. is a provider under your insurance plan,
HMO, PPO. It is your responsibility to provide the necessary insurance information to do so, including authorizations. If this information is not provided at time
of visit you will be required to make payment for services rendered.
Out-of-network Provider - If Mrs. Wilkinson MS, RDN, LD is not a provider under your Insurance Plan, we will not file your Insurance.
You will be provided with a superbill that includes the Insurance coding needed for reimbursment. You can submit it to your Insurance Company or apply it
toward a Flex Spending account.
*** Your Insurance is a contract between you and your Insurance carrier, and does not guarantee payment for nutrition services and/or payment to Mrs.
Wilkinson MS, RDN, LD. Ultimately it is your responsability to be aware of your insuranceand referral coverage.
NutritionECW.com cannot become involved in disputes regarding claims, deductibles, co-payments, non-covered charges or other denials of payment.
NutritionECW.com is required to collect any client responsibility, as this is part of our HMO/PPO contract. If you have any question regarding your Insurance
coverage please direct them to your insurance representative. If you fail to pay your account, you will be responsible for any collection fees incurred. This
includes processing fees if your account has to be placed with a third party for collection.***
Deductible and co-payment or co-insurance
You agree that you will pay any deductible and co-payment or co-insurance as determined by your insurance plan. Those payments will be collected at the
beginning of your appointment. Many insurance companies have additional requirements or stipulations that may affect your coverage.
Payment - We accept payment by credit card (Discover, Visa, MasterCard, American Express, Diners Club International & PayPal), check, and cash. There is a $35 fee
for any returned checks. All payment of fees for a returned check and further payments will be due in cash, or credit card only.
***Credit/Debit card information***
At your first visit, you must show the Credit/Debit card that will be stored in your record and you authorize the saving of your card on file for future use. You can use a Health Flex Spending card or
medical saving accounts at the time of the visit but NOT to be stored in your file. All co-payments or payments will automatically be discounted from your credit card if your Insurance denies coverage. In case
a refund is needed, our practice will refund it to that same credit card. You will always receive a secure email notification with a transaction receipt. This card will also be used for refunds or to void payments.
Schedule, missed and cancelled appointments - All appointments must be cancelled at least two business days (excludes Saturday and Sunday) prior
to the day of the appointment. Patients who fail to comply with this policy will be charged a $50 fee to their account (not your insurance company).
Discounts packages or Skype sessions fees are paid in advance. We will not be refunded or exchanged and the appointment will be forfeited if client
does not show up or cancel the appointment within less than 2 business days in advance.
I have read and understand the financial policy described above.
I agree to pay, promptly and in full, any amount due to the provider, including co-payments, deductibles, and any amount due for non-covered services that
are not payable by my insurance.
I authorize any holder of medical or other information about me to release to the Social Security Administration and Health Care Financing Administration or
its intermediaries or carriers any information needed for this or a related any Insurance Company claim. I permit a copy of this authorization to be used in
place of the original, and request payment of medical insurance benefits either to myself or to the party who accepts assignment.
I understand it is mandatory to notify the health care provider of any other party who may be responsible for paying for my treatment. (Section 1128B of the
Social Security Act and 31 U.S.C. 380 1-3812 provides penalties for withholding this information.)
Patient Name ......................................................................................... SSN ................................ Signature ............................................... Date ..............................
NutritionECW,LLC - Medical Nutrition Therapy
NutritionECW,LLC - Medical Nutrition Therapy
Statement of Patient Financial Responsibility