Advanced Beneficiary Notice of Non-coverage (you must read and sign)
I hereby certify that the above information is true and correct to the best of my knowledge.I hereby authorize Kingwood Health & Wellness Clinic to release any of my information required for continued care to other Providers that I may utilize for my care. I understand and gree, that I am financially responsible for any balance owed for my care. This is a fee for service clinic. Payment is due on the day of service.We will NOT authorize lab slips or lab testing and that the lab testing must be done outside of any insurance plan. Dealing with insurance companies and HRT (hormone replacement therapy) has been difficult and insurmountable. We, therefore, wish to advise you that any treatment will not involve any use of insurance or completing insurance forms, statement of medical necessity or prior authorizations. Your telephone number is collected to send appointment reminders as well as clinic specials. You may "opt out" of receiving texts at any time. Signing below indicated that you understand and consent to treatment and agree to receive our text reminders.
We strive to achieve optimal health & wellness through nutrition, exercise, hormone balance and optimization. Our programs, protocols and philosophy are designed to maximize your QUALITY of life. If your hormone levels are in normal range but are low and you have symptoms, we may start therapy to alleviate symptoms.