7656 W. Sahara Ave Ste 110, Las Vegas, Nevada 89117
Phone: (702) 525-1105 Fax: (702) 666-8555
I certify that the above is true and correct to the best of my knowledge. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.
As a Registered Dietitian & Certified Diabetes Educator, my services are personalized to your needs and comfort level. It is my goal to provide you with an understanding of your medical condition, such as diabetes, medications, and the effects of diet and exercise on disease management. At each visit, we will set a treatment plan with action items that will positively affect your health. At this time, I have contracted other Registered
Dietitians to work within my business. Your dietitian provider has been chosen by your current medical condition, medications, referring physician and/or your laboratory results.
I accept all insurances, however, at this time; I am not contracted with all insurance carriers. When insurance companies process a claim for an out-of-network provider one of two things happen; 1) The insurance carrier will apply the entire charged amount to the patient’s out-of-network deductible or 2) The insurance company will deny the claim in it’s entirety making the subscriber financially responsible for the full billed amount. Understanding the financial burden this would create I have significantly reduced my fees to $90.00 an hour per 60 minute visit & $50.00 for a 30 minute visit for patients who have insurance which I am not yet contracted with.
It is your responsibility to pay any deductibles, co-pays or remaining balances to your account upon receipt of your statement. If your account has a balance after 6 months from the date of service, we will send your account to our collection agency, Plus Four Inc, to collect payment and additional interest and fees may apply.
Law requires the privacy of your health information to be maintained as confidential and not shared with any outside parties. Your Dietitian for Diabetes & Weight Control will not disclose any of your health information to any outside organizations, with the exception and purpose of:
This is a summary of our disclosures practices. Full disclosure packet is available upon request at the front desk.
I understand that if I wish to place any restrictions on Your Dietitian for Diabetes & Weight Control, LLC Health Information Policy, I must make my request in writing. My request can be placed at any time. Your Dietitian for Diabetes & Weight Control will review my request and respond within 30 days. I will address concerns to;
Your Dietitian for Diabetes & Weight Control, LLC
Please provide the best contact telephone number for appointment reminders or email.
Once you receive a text or voice reminder we ask that you confirm your appointment as soon as possible. We are using an automated confirmation system so please READ and reply as stated in the reminder (it is usually a number You can leave a voicemail or text our office 24-hours a day at 702.525.1105.