Treatment Agreement

Confidentiality

Health Information Portability and Accountability Act (HIPAA) Notice of Privacy Practices is adhered to. The HIPAA notice is available for viewing in the waiting room. A copy can be requested and its part of this introductory package.

Appointments

Appointments run approximately 50 minutes. We encourage you to book several appointments in advance to ensure a time slot that works best for you.

Payment & Insurance

Full or insurance co-payment is due at time of service. Cash or check made payable to CNC360 accepted. If CNC360 is a contracted provider with your insurance, a bill will be submitted to your insurance. Gail Evans handles billing administration. You can contact Gail at (480) 332-7993 for any billing questions. You are responsible for any bank fees on a returned check. You are responsible for informing CNC360 of any changes in your insurance coverage and contact information.

Referral Waiver

You are responsible for educating yourself about the terms of your insurance coverage for medical nutrition therapy and whether you require a referral from your primary care provider. If you receive services without the appropriate referral and/or you insurance carrier denies payment, you are responsible for payment. We request that you have your doctor’s office fax a copy of your referral that includes the authorization number to our office in order to process the claim.

Cancellation Policy

Once a session is scheduled it becomes your responsibility to attend, reschedule or cancel it. To cancel or change an appointment, please call the clinician’s individual voice mail and leave a message. A minimum of 48 business hours noticed is required to cancel an appointment. Monday thru Friday are business days. To reschedule or cancel for Monday, call by Thursday; for Tuesday, call by Friday. You are responsible for the full charge of the appointment, not just the co-payment, for missed appointments and late cancellations (less than 48 business hours), except in cases of emergencies. This fee is due by the next appointment.

Phone Consultation

Phone consultation is not covered by insurance. Phone sessions longer than 15 minutes will be pro-rated per hourly rate.

Communication

Messages for CNC360 clinicians should be left on their individual voicemail. We will make every effort to return calls within 48 hours. If your call is urgent in nature, please contact your physician or go to your local emergency room. Text messages and emails are not reliable or confidential modes of communication, therefore we do not usually participate in their use.

Thank you for your cooperation and understanding.