Please fill out this form to ensure you have insurance coverage for nutrition counseling/medical nutrition therapy.

Call your insurance company number on the back of your card. You are responsible for any charges your insurance will not cover.

CPT codes: 97802 and 97803

Download and fill out this form before your first appointment.

Telehealth Consent

Please fill out and submit this form to consent to telehealth/telemedicine appointments, including insurance coverage changes.

Please download, sign, and email to shelbyerinrdn@gmail.com

Please download, sign, date, and bring this form allowing me to bill your insurance for these benefits. If telehealth, please download, e-sign, and email to shelbyerinrdn@gmail.com

HIPAA Notice of Privacy

Please download, sign, date, and bring this form to your first appointment

If you did not already provide a card on file through your insurance verification above, please print and bring this form to your first appointment, it will be kept secure. If you do not wish to provide a card on paper, you can bring your card to your first appointment, virtually or in-person, and it will be stored securely in your patient chart. However, we still need your signature on file, so please download, sign, and return.