Forms

Providers, to refer a new patient who requires a referral, please fax us this Refer a Patient Form.

New patients,
You will need to complete Intake Documents prior to your 1st appointment.   We will need the following information when scheduling your first appointment:

• Your Name and Name of Primary Person on your Insurance,
• Your Date of Birth
• Date of Birth for Primary Person on your Insurance
• Cell Phone (parent/guardian if under 18 years old)
• E-Mail (parent/guardian if under 18 years old)

After you schedule an appointment, you will receive an e-mail from Patient Ally to set up your Patient Portal. You will receive a Patient Ally enrollment invite with a security code through your cell phone.  Then log in to your Portal to access the new patient forms under the “Documents -> Intake Documents” tab.

You will complete the following forms:

• Medical History (required)
• Policies, Demographic, Insurance, Release Of Information (required)
• Insurance Financial Agreement (required)
• Self-Pay Agreement (required self-funded plans, plans that pay for limited service (BCBS/Anthem) & for those not using insurance)
• Assumption Of Risk (required to leave office for walk, meal or experientials)
• Credit Card/HSA Card Authorization (required for copays and balance)  Copays are due at the time of your appointment.  We accept cash, check, Visa or MasterCard.
• Privacy Policy (HIPAA) 

We require that you have a valid credit card or HSA card on file with our office for payment of your balance after insurance processes. Co-payments can be paid at the time of your visit with the payment method of your choice (cash, check, Visa, Mastercard, AMEX or Discover) or with the card on file. In no circumstances can we waive co-payments. Services that insurance does not cover, require payment in full at the time of service unless other arrangements are made in advance.  The  insurance companies Christina Scribner is associated with provide payment for many of the services at Encompass Nutrition LLC, but not necessarily all.

Please know that we do not participate with the Medicare or Medicaid program.
Please also understand that your particular insurance carrier covers only those benefits and treatments as outlined in your insurance policy.  You may be responsible for additional payments above and beyond what your insurance company benefits may cover.

Insurance. Please confirm your medical plan coverage with your insurance provider; “In-network status does not guarantee plan coverage for nutritional therapy.”  Even though we may be “in-network” with your insurance carrier, your specific plan benefits may be either comprehensive or narrow/limited in terms of the providers that they consider in-network.  It is your responsibility to determine your own coverage benefits.

United Healthcare (most plans)