- Physician Referral Form (PDF)
- Authorization for Disclosure of Health Information (PDF)
- Verification of Insurance Benefits (PDF)
- Advance Beneficiary Notice of Non-coverage (PDF)
The “Physician Referral Form” must be completed by your healthcare provider and faxed to our office. You and your healthcare provider may need to complete the “Authorization for Disclosure of Health Information” form if you wish for your medical records to be shared between LE-Nutrition LLC and your healthcare provider(s).
Utilize the “Verification of Benefits” form to call your insurance provider and CONFIRM your benefits PRIOR to your appointment. You are held 100% responsible for any fees that are not covered by your insurance (review full disclosure in your “Client/Practitioner Agreement.”
An “Advance Beneficiary Notice of Non-coverage” is for individuals with Medicare when benefits are NOT COVERED.
Submit completed forms via your patient portal or FAX them to 682-316-9294. If you have any questions regarding patient forms, please contact us at 682-235-9884 or via your patient portal.