To make sure you are covered by insurance, please complete the form below.

* Indicates required field

Choose one of the following options regarding checking your insurance benefits:

I want to move forward WITHOUT checking my insurance benefits - please complete SECTION 1 of this form and skip SECTION 2, then click the SUBMIT button at the bottom of this page.

I plan to follow the steps below and call my insurance to check benefits - please complete SECTION 1 & SECTION 2, then click the SUBMIT button at the bottom of this page.

Please Note:

From the options above, you can move forward WITHOUT checking your benefits (completing SECTION 1 only) and set up a session with a clinician at Nourishment Works, PC or follow the steps in SECTION 2 and check your benefits. If you do not check your benefits, you give Nourishment Works, PC permission to submit claims to BCBS PPO, BCBS Choice PPO, and Medicare plans only (as these are the insurance carriers we are in network with at this time) and understand that you will be held responsible for any and all out of pocket costs your insurance plan does not cover. We highly recommend following the steps below, completing SECTION 1 and SECTION 2 to checking your benefits.

SECTION 1

Enter your current insurance information.

Client type

If patient is a minor, Parent/Guardian's name (party responsible for communication of billing and/or appointments)

First Name

Last Name

Patient name

First Name

Last Name

Patient legal name (if different from above)

First Name

Last Name

Patient's date of birth

YYYY

Patient's email

If patient is a minor, Parent/Guardian's email (party responsible for communication of billing and/or appointments)

Patient's phone

(###)

###

####

If patient is a minor, Parent/Guardian's phone

(###)

###

####

Patient sex (Please choose the sex that corresponds with the information that is on file with your insurance company. It is required if you plan to use your insurance or file a claim. Please note: "Female" and "Male" are the only options provided by the insurance company at this time)

Primary health insurance carrier

If other, please specify

Do you have a secondary health insurance carrier?

If yes, please specify

Through which state is your insurance?

If other, please specify

Is this in regards to diabetes?

Who is the primary subscriber?

Legal name of subscriber

First Name

Last Name

Subscriber sex (Please note: "Female" and "Male" are the only options provided by the insurance company at this time)

Subscriber's date of birth

YYYY

Subscriber's phone number

(###)

###

####

Subscriber's email address

Subscriber's address (please enter the address on file with the insurance company)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Insurance plan name

Member ID (please include ALL LETTERS & NUMBERS)

Group number (please include ALL LETTERS & NUMBERS)

Front of Insurance Card *

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Back of Insurance Card *

FileField;MaxSize=5120;Multiple;addText=Add_your_Files;

SECTION 2

Call your insurance carrier to check benefits

Next Step: Call your insurance carrier

In order to properly check your benefits, please read these step by step instructions and complete this form. Once completed, we will reach out to you and get you set up to begin working with one of our dietitians. While we are "in network providers" with BCBS PPO & BCBS Choice PPO, each client policy is unique, which is why we request you check your benefits prior to your appointment. Use this form to check in and out of network benefits. 1. Please call the Customer Service number on the back of your insurance card. 2. When calling, you may be asked for the following information about our practice: Nutritional Counseling sessions are billed as medical office visits. Our office address is 3921 N Lincoln Ave. Chicago, IL 60613. Tax ID#: 810890984 Type 2 Group Practice NPI#: 1881169027 (Nourishment Works) Type 1 Rendering NPI#: 1285681080 (Kathryn Merkle, Owner) Please check all of the following procedures codes (CPT codes): 97802 - Initial visit 97803 - Follow up visit 97804 - Group session Diagnostic code: If you have a specific diagnosis code from your MD, therapist, or care provider please provide that to the representative to check. Please note that although the diagnosis code may fall under mental health, seeing a dietitian falls under medical. A typical code we use in our practice is Dietary counseling and surveillance: Z71.3. Please check to see if there is any coverage or exclusions for CPT code Z71.3.

Script: “I’m calling to check [in or out of] network benefits for Nutrition Counseling. I need to check 3 CPT codes: 97802, 97803, & 97804."

"Are nutritional counseling benefits under preventative or medical?"

Preventative

Medical

Both

"Please give me the benefits for both preventive and medical?"

"Are nutritional counseling benefits covered at 100% or is there a copay, coinsurance, deductible or out of pocket involved?"

Covered at 100% of the allowed amount

A copay/coinsurance applies

I must meet my deductible before coverage applies

I must meet my individual or family out of pocket max

Please enter any additional notes here such as copay, coinsurance, deductible or out of pocket amounts:

"Are there any visit limits or visit max?"

No limit on visits

Yes, there is a limit on visits

"If there is a visit limit/max, is it a 'soft' limit or 'hard' limit?"

"If there is a visit limit, have any of the allowed visits been used?"

Yes

N/A

Please enter additional notes here regarding visit limits:

"Is pre-authorization or pre-certification needed for Nutritional Counseling?"

"Do I have telehealth/telemedicine benefits for Nutritional Counseling?"

Date you called your insurance:

YYYY

Reference Number for the call:

Ask the representative for the reference number for the call and enter it here:

Insurance Disclaimer:

“Please be advised that a quote of eligibility and benefits is not a guarantee of payment. All benefit payments are subject to eligibility, medical necessity and the terms, conditions, limitations, exclusions and payment levels of the patient’s health benefit plan at the time the services are rendered. Benefit payments are usually not determined based on billed charges and might be significantly less than billed charges. Exact benefits will be determined when a claim is received.”

Thank you! We will review the information you’ve provided, confirm that your insurance is active and be in touch with you to move forward in the process of getting you all set up. Please contact our biller at billing@nourishmentworks.com if you have any questions. We look forward to working with you!

~ The Nourishment Works Team

Checking your benefits

Verification of benefits script & form

Nourishment Works

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