Customer Responsibility Agreement

Customer Responsibility Agreement

CUSTOMER RESPONSIBILITY AGREEMENT: In order to accurately process claims, it is the responsibility of the patient to
supply Nourishing Medicine with correct information. By signing, the patient agrees to divulge any change to their
insurance policy, contact information, change in medical condition or change in residential status (i.e. admission to
hospital/healthcare facility). Failure to update this information may result in any or all related charges to be billed to the
patient.

ASSIGNMENT OF BENEFITS: By signing below, the patient: 1) Authorizes Nourishing Medicine to contact the patient by
phone or mail regarding supply orders, billing or additional information needed to process claims. 2) Releases pertinent
medical information to be sent to their insurance carrier and their agent and assigns Nourishing Medicine to obtain any
medical information necessary in order to process claims. 3) Authorizes Nourishing Medicine to conduct direct billing of
their insurance carrier for the items furnished on this day.

FINANCIAL RESPONSIBILITY AGREEMENT: It is the responsibility of the patient to verify their coverage for services
rendered with their insurance carrier. Final patient responsibility is determined once the patient’s current insurance has
processed and paid for the services rendered on this day. By signing below, the patient agrees to pay all coinsurance,
deductible, or non-covered amount determined by their insurance carrier.

Legal Name

Date of Birth

Date Signed

E-Signature

admin none 8:00 AM - 4:00 PM 8:30 AM - 1:00 PM 10:00 AM - 6:00 PM 10:00 AM - 5:00 PM Closed By Appointment Only Closed nurse practitioners # # # 200 West lincoln Highway,
Waterman, IL 60556