Forms

North Shore Nutrition Consultants, LLC accepts the following insurance plans:

View our HIPPA Notice

New Patient Form

Patient Details


Contact


Primary Care


Insurance

Bring your Insurance Card to the appointment.

Please note that not all insurance companies cover nutrition counseling and medical nutrition therapy. Contact your insurance company prior to your visit to determine if they cover nutrition counseling and whether they cover the reason for your visit. Determine if you require a referral. If your physician suggested you meet with North Shore Nutrition Consultants, LLC, it does not mean you are automatically covered. A referral is not a guarantee of coverage. The patient is responsible for all co-payments, deductibles, non-covered charges/services.

If you have more than one insurance plan, you MUST use your primary plan.

Misc

Co-payment charges and appointment fees are required to be paid at each visit. Credit cards, FSA Cards, checks and cash are accepted. If a check is returned for insufficient funds, I understand I will be charged a $35 fee.

I understand and agree that I will be held fully responsible for all non-covered charges related to my appointments with North Shore Nutrition Consultants, LLC. I understand that North Shore Nutrition Consultants, LLC may not be a participating practitioner with my insurance company/provider. If I fail to show up for my scheduled appointment or cancel my appointment within 24 hours of the appointment, I understand that I will be charged a “no show” fee of $90. I understand that if I am late to my appointment, I will forfeit the missed time. If I am more than 15 minutes late to my appointment, it will be considered a “no show”.

I understand that I am working with North Shore Nutrition Consultants, LLC to obtain medical based nutrition therapy information and counseling. This information supports my own efforts in nutrition, diet and behavior for my personal health and wellbeing. I understand that nutrition counseling is not a substitute for diagnosis, treatment or care of a disease by a physician.

I give permission to North Shore Nutrition Consultants, LLC to leave a voice mail to the numbers I have listed as well as permission to contact me at my provided email address.

I have read North Shore Nutrition Consultants, LLC’s office policies and agree to the terms. I understand that if insurance coverage is denied, I am responsible for payment. I understand that I will be responsible for any fees incurred in collecting unpaid balances such as; collection agency, bounced checks or attorney.

Authorization to Obtain/Release Confidential Medical Information

Patient Details

I authorize North Shore Nutrition Consultants, LLC to share my progress and health care information with medical professionals and the following individuals.


Primary Care Physician


Referring Physician/NP/PA


Specialist (Cardiologist, Endocrinologist, Allergist, etc.)


Mental Health Therapist


Other

I understand that my records and treatment is confidential. They will not be disclosed without my consent. I understand I may revoke this consent at any time.