• 2518 Ocean Parkway
    Brooklyn, New York, 11235
  • WE ARE OPEN

    Monday to Friday 10:00 AM - 05:00 PM

FINANCIAL AGREEMENT FORM

Sandy Zohni MS RD CDE CDN
2518 Ocean Parkway
Brooklyn, New York, 11235
T: 718-376-1616
E: mydietconnection@gmail.com

Thank you for choosing our nutrition counseling services for your dietary and health needs. Please read and sign the agreement below. It lays out billing, scheduling, and cancellation procedures. If you have any questions, please ask for clarification.

Payment of all fees is expected at the time of service . This includes co-payments and out of pocket fees.

It is the patient’s responsibility to check insurance benefits and coverage. However, verification of eligibility DOES NOT guarantee payment by the insurance. Patients will be responsible for any services that do not get covered, deductibles, co-payments, or co-insurances, as determined by your insurance carrier.

I hereby authorize payment of medical benefits directly to Sandy Zohni Dietetics/Nutrition PLLC for all services rendered where applicable.

Out-of-pocket payments can be made via Quick pay, Zelle, Venmo, cash or check and are due on the date of your appointment. Please make checks payable to Sandy Zohni Dietetics/Nutrition PLLC. There is a $35 fee for all returned checks.

I hereby authorize Sandy Zohni Dietetics/Nutrition PLLC to release to government agencies, insurance carriers and all others who are financially liable for my care, all information to substantiate payments for my care and to permit representatives thereof to examine and make copies of all records related to such care and treatment. I understand that if at any point my insurance coverage changes, I am to notify administrative staff prior to my next visit. Failure to do so will result in being personally and completely responsible for the full amount of all services.

I will be responsible to pay a $50 cancellation fee for any missed or cancelled visits, not made at least 24 hours in advance prior to the scheduled appointment time.

  • AGREE TO THE ABOVE FINANCIAL AND CANCELLATION POLICIES. IN THE CASE OF DEFAULT PAYMENT, I AM RESPONSIBLE FOR FULL PAYMENT OF THE BALANCE, INTEREST ACCRUED, AND ANY COLLECTION COSTS AND LEGAL FEES INCURRED TO COLLECT ON THIS ACCOUNT. I UNDERSTAND THE SCOPE AND LIMITATIONS OF MY INSURANCE COVERAGE AND AGREE TO PAY ALL FEES NOT COVERED BY MY INSURANCE PLAN. I HAVE READ, UNDERSTAND, AND ACCEPT THE INFORMATION AND CONDITIONS SPECIFIED IN THIS AGREEMENT.
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