Patient Financial Agreement
Financial Agreement: I understand that all charges are due at the time of service, and that there are no refunds on prepaid treatments. I agree to pay Nourish Your Life for all charges for nutrition therapy provided to me, or my dependent. Acceptable forms of payment include cash, check, Venmo, Visa, MasterCard, American Express, Discover, JCB, debit cards, health savings account (HSA) cards, and flexible spending account (FSA) cards. If I am a non-insured patient, I agree to pay for my visit in full at the time of service. If Nourish Your Life is a participating provider with my insurance company I understand that my co-pay, coinsurance, deductible and/or any outstanding balances are due at the time of service.
Insurance Authorization and Release: I request that payment of authorized benefits, including Medicare and any other government sponsored program, private insurance, and any other health plans be made to Sandy Kipp RDN LLC, private practitioner for services provided.
Nutrition counseling with a holistic approach is time intensive and requires blocks of time that average 1-2 hours per consultation. In consideration of Sandy’s time and of other patients wishing to book appointment slots, a 72 hour (not including weekends) notice of cancellation is required.
By signing this agreement you acknowledge that you understand the above cancellation policy. If you choose to cancel within 72 hours of your appointment (not including weekends) you agree to pay a $45 cancellation fee.
By signing below, I acknowledge that I understand and will adhere to the Privacy, Financial, and Cancellation Policies of Nourish Your Life.