Authorization to Bill Insurance, FL Nutrition Group LLC
After completing and reviewing the information below, please type in your full name and your scheduled appointment date at the bottom of the page. 

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Please indicate whether this is an INITIAL of FOLLOW-UP appointment.  *
Initial
Follow-up
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Patient's legal FIRST and LAST Name:  *
Guardian's legal FIRST and LAST Name (if applicable): 
Home Address:  *
Email Address:  *
Patient Date of Birth:  *
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Patient Phone Number(s):  *
Name of Insured:  *
Relationship to Insured:  *
INSURED Date of Birth:  *
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Medicare Policy Number:  *
Do you have a secondary form of insurance?  *
Secondary Insurance:
Secondary Insurance ID: 
Secondary Insurance Policy#: 
Referring Physician (Name and Contact): *
Please review the following information before typing your name below: 

I, the undersigned, hereby certify and attest that I have sought medical nutrition therapy from a registered dietitian at Florida Nutrition Group LLC. I authorize FL Nutrition Group LLC to release the insurance details provided above to Medicare for the purpose of determining and receiving benefits for medical bills. 

I understand and acknowledge that the medical staff will submit my claim through a third party billing company on my behalf. All private health information will be kept confidential as required by HIPAA guidelines. 

I understand that my typed name below is a proxy for my signature. 

Patient First and Last Name:  *
Date of Scheduled Appointment: *
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