Providers, to refer a new patient, please fax us this Refer a Patient Form.
Please print and bring completed “required” forms with you to your 1st appointment.
Print and Complete the following to bring to your 1st appointment.
- Medical History (required)
- Policies, Demographic, Insurance, ROI (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.
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 with Christina Scribner is associated provide payment for many of the services at Encompass Nutrition LLC.
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.”
Phone: 888-PHR-4ALL (888-747-4255)