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You're Taking the First Step to Work with a Registered Dietitian and Transform Your Health Forever 🎉 Please read this, it's important...

You're Taking the First Step to Work with a Registered Dietitian and Transform Your Health Forever 🎉 Please read this, it's important...

Photos must be clear or we will be unable to proces your request. ⚠️ Verification of benefits is NOT a guarantee of benefits. As the patient YOU ARE RESPONSIBLE for understanding your benefits and financially responsible for services not covered. By completing this form you understand and agree. ⚠️
9Questions

HIPAA

Compliance

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    • Ecuador
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    • Madagascar
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    • Nepal
    • Netherlands
    • Netherlands Antilles
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    • New Zealand
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    • Nigeria
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    • Northern Mariana
    • Norway
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    • Palau
    • Palestine
    • Panama
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    • Paraguay
    • Peru
    • Philippines
    • Pitcairn Islands
    • Poland
    • Portugal
    • Puerto Rico
    • Qatar
    • Republic of the Congo
    • Romania
    • Russia
    • Rwanda
    • Saint Barthelemy
    • Saint Helena
    • Saint Kitts and Nevis
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    • Saint Martin
    • Saint Pierre and Miquelon
    • Saint Vincent and the Grenadines
    • Samoa
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    • Saudi Arabia
    • Senegal
    • Serbia
    • Seychelles
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    • Trinidad and Tobago
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    • Tunisia
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    • Turkmenistan
    • Turks and Caicos Islands
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    • Ukraine
    • United Arab Emirates
    • United Kingdom
    • United States
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    • Vatican City
    • Venezuela
    • Vietnam
    • British Virgin Islands
    • Isle of Man
    • US Virgin Islands
    • Wallis and Futuna
    • Western Sahara
    • Yemen
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    • Zimbabwe
    • Other
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    This is also to help us properly verify benefits.
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    Please also note: DIAGNOSIS and/or FAMILY HISTORY to help us properly verify benefits.
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    If the photo is not legible we will not be able to verify your benefits.
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