get verified.Complete the first few fields with your demographics and then call the number on the back of your insurance card to complete this form. They may ask you for the following information about the practice:Group NPI: 1184381832Provider NPI: 1437728185 EIN 87-1253367 Name * First Name Last Name Email * Date of Birth * MM DD YYYY State of residence * Due to licensing laws, our services are offered to adults in AZ, CA, CO, IL, MI, OH, VA, & WI. Arizona California Colorado Illinois Michigan Ohio Virginia Wisconsin Name of Insurance * Example: Blue Cross Blue Shield, Cigna, Aetna, United... What is the name of the insurance representative? * Is the ICD 10 code Z71.3 covered? * yes no Is the ICD 10 code Z72.4 covered? * yes no What is my policy type? * PPO HMO POS Other If other, please list here: What is my benefit period? * Is this a FULLY funded plan? * yes no Is this a SELF-funded plan? * yes no Is this policy a grandfathered plan not needing to adhere to the ACA? * yes no Does this policy have Nutrition Counseling/Medical Nutrition Therapy Benefits? * yes no Which CPT codes are covered on this policy? * Select all that apply. 97802 97803 97804 S9470 99470-99404 Are BOTH preventative nutrition services covered under Health Care Reform AND medical benefits covered? * yes no Does this plan cover telehealth services? * yes no Is there a copay for services? * yes no If there is a copay, what is the amount? Does this plan require a doctor referral? * yes no Does this plan require the dietitian submit medical documentation? * yes no If yes, what is the fax number to send these notes? How many visits for PREVENTATIVE nutrition therapy are covered each year? * Is there a limit on the number of units billed per a PREVENTATIVE visit? * yes no If yes, what is the limit on the number of units billed? Do I have a cost-share for my PREVENTATIVE nutrition visits? * yes no If yes, is this in the form of a co-pay, co-insurance, or deductible met? Note this type and amount if applicable. How many visits for MEDICAL nutrition therapy are covered each year? * Do I have a cost-share for my MEDICAL nutrition visits? * yes no If yes, is this in the form of a co-pay, co-insurance, or deductible met? Note this type and amount if applicable. Ask for a reference number for this call. *
