MEDICARE - Personal Information Form

MEDICARE - Personal Information Form

A. Notifier: NutritionECW, LLC - Medical Nutrition Therapy. 6300 Hospital Pkwy. Ste 225. Johns Creek - GA 30097. Phone # 678-407-2159.
Name of your Medicare doctor, PCP or DO*

First NameLast Name
Office Phone #*
Please enter a valid phone number.
B. Patient's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Phone #*
Email*
example@example.com
C. Identification Number - Primary Health Insurance*
Primary Subscriber ID#*
Secondary Health Insurance
Secondary Subscriber ID#
Language
REASON to see a Registered Dietitian. Please, detail the reasons why you requested this visit.*
Have you ever consulted a Medicare Registered Dietitian? *
If yes, when was that visit and how many visits you had?
Have you been hospitalized? When? What was the reason? *
Who takes care of you? Who helps you with your food?
DIAGNOSIS covered by Medicare

Please click on ALL the diagnoses you present
Type 1 DIABETES MELLITUS (DM)

E10.9 - Type 1 DM w/without complicationsE10.6 - Type 1 1 DM w/other specified complicationsE10.65 - Type 1 DM w/hyperglycemiaE10.2 - Type 1 DM w/kidney complicationsE10.64 - Type 1 DM w/ hypoglycemiaNone
Type 2 DIABETES MELLITUS (DM)

E11.9 - Type 2 DM without complicationsE11.6 - Type 2 DM w/other specified complicationsE11.64 - Type 2 DM w/hypoglycemiaE11.2 - Type 2 DM w/kidney complicationsE11.65 - Type 2 DM w/hyperglycemiaE11.8 - Type 2 DM w/unspecified complicationsZ79.4 - Long term (current) use of insulinNone
CHRONIC KIDNEY DISEASE (CKD)

N18.1 - CKD, stage 1N18.4 - CKD, stage 4N18.2 - CKD, stage 2N18.5 - CKD, stage 5N18.31- CKD, stage 3aZ48.22-Aftercare following kidney transplantN18.32 - CKD, stage 3b
Other medical conditions

Weight Management: obese, overweight, etcHypertensionAbnormal lipid panel (elevated cholesterol, Triglycerides, etc_Abnormal weight loss or Underweightgastrointestinal issues (which ones)
MEDICATIONS and SUPPLEMENTS that you are currently taking.
Any additional information you want to disclose to us?
Please, upload LABORATORIES / medical notes or FAX 678-780-4313

Cancelof
Advance Beneficiary Notice of Noncoverage (ABN)

An Advance Beneficiary Notice of Noncoverage (ABN) is a Medicare waiver of liability that providers are required to give a Medicare patient for services provided that may not be covered or considered.

Please, read and sign your ABN so you can make an informed decision about your care.

NOTE
- Medicare will ONLY cover MNT for diagnoses of diabetes and non-dialysis kidney disease, when a Medicare beneficiary has been referred by a physician. We do have a Medical Referral form from our website that your doctor can complete.
- If Medicare doesn’t pay because you do not have the Medical Referral Form signed by your doctor o because you do not meet the diagnose criteria, you may have to pay.
Medicare does not pay for everything, even some care that you or your health care provider have good reason to think you need. We expect Medicare may not pay for Medical Nutrition Therapy listed below.

WHAT YOU NEED TO DO NOW:
• Read this notice, so you can make an informed decision about your care.
• Ask us any questions that you may have after you finish reading.
Choose an option below about whether to received Medical Nutrition Therapy (D) listed above.
(G) OPTIONS: Check only one box. We cannot choose a box for you.NOTE: If you choose Opt.1 or 2, we may help you to use any other insurance that you might have, but Medicare cannot require us to do this.

OPTION 1. I want the (D) service listed above. You may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn’t pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN. If Medicare does pay, you will refund any payments I made to you, less co-pays or deductibles.OPTION 2. I want the (D) service listed above, but do not bill Medicare. You may ask to be paid now as I am responsible for payment. I cannot appeal if Medicare is not billed.OPTION 3. I don’t want the (D) service listed above. I understand with this choice I am not responsible for payment, and I cannot appeal to see if Medicare would pay. Our practice does not accept patients who select this option.

D.MEDICARE

SERVICES COVERAGE

E.Reason MEDICARE
May Not Pay

F.Estimated Cost

if Medicare denies coverage

Medical Nutrition Therapy
(MNT)

Nutritional counseling

Medicare will ONLY cover MNT for diagnoses of

Diabetes
non-dialysis kidney disease
36 months post kidney transplant

Face-to-face

IN OFFICE

$225.00 - first visit
$225.00 - second visit
$170.00 - follow-up visits

Medicare pays for

3 visits of MNT in the first year and
2 visits in every year after that

Face-to-face

VIRTUAL VISITS

$150.00 per visit

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Name*

First NameLast Name
Date

YearMonthDay
Date
Hour MinutesAM/PM Option
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MEDICARE - Personal Information Form

DIAGNOSIS covered by Medicare