Web Insurance Payer Form

Insurance Payer / Reimbursement Form

In-Network Coverage: Aetna, BCBS, Cigna, United Health Care
Please fill out our quick Insurance Payer / Reimbursement Form.

Once complete you will be redirected to choose your nutritionist and schedule your appointment, if you have not already.

Well-Choices will contact your Insurance Provider for approval, depending on your coverage, Well-Choices will bill the co-pay or difference owed to your credit card.

If your insurance provider is out of network, the full cost will be charged to your credit card and Well-Choices will automatically submit a "Superbill" reimbursement form to your Insurance Provider on your behalf.

You can cancel the program at any time by emailing info@well-choices.com.Terms, and conditions can be found at Well-Choices.com/terms-conditions-check-out/

CC Authorization Form

I authorize Well-Choices to charge my credit card as payment for any balance due as a result of my insurance plan's coverage, deductible, co-insurance, or co-payment. I understand that my insurance plan may not cover the services provided and that I am responsible for the charges incurred. I understand and agree that this form is valid until I cancel my Well-Choices counseling program.
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Insurance Payer / Reimbursement Form