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I request that authorized insurance benefits are paid on my behalf to LBS Nutrition LLC for services rendered to me. Additionally, I authorize any holder of medical information about me to release it to our office for the rendering of services and the processing of insurance billings. I certify that all the information provided by me on this form is true and accurate. I have received/reviewed the HIPPA Privacy Notice of this office and hereby guarantee, acknowledge responsibility for, and will assume payment of all charges against this account as they accrue. This includes agreeing to pay the $35 missed appointment fee out of pocket.
Televisits | Offices in East Brunswick, Manalapan & Somerset | email@example.com