Medical Release Form

Date *

Medical Facsimile

Cover Sheet

TO:

Doctor Name/Clinic Name *

Clinic Phone

Clinic Fax

FROM:

Name:

Natural Healing Care Center IIc

SIGNATURE:

DAVID YRIGOYEN

PHONE

520-323-0069

FAX

520-300-8484

First Name *

Last Name

Identifier *

REASON FOR RELEASE:

MEDICAL EVALUATION

INFORMATION RELEASED:

PAST TWO VISITS

IMPORTANT: This facsimile transmission contains contains confidential information, some or all of which may be protected health information as defined by the federal Health insurance Portability & Accountability Act (HIPAA) Privacy Rule. This transmission is intended for the exclusive use of the individual or entity to whom it is addressed and may contain information that is proprietary, privileged, confidential and/or exempt from disclosure under applicable law. If you are not the intended recipient (or an employee or agent responsible for delivering this facsimile transmission to the intended recipient), you are herby notified that any disclosure, dissemination, distribution or copying of this information is strictly prohibited and may be subject to legal restriction or sanction. Please notify the sender by telephone (number listed above) to arrange the return

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Disclaimer

Naturopathic Doctor Visit Insurance Reimbursement Disclaimer:
Natural Healing Care Center currently does not accept insurance for naturopathic services. However, we can assist with out-of-network deductions by providing an ICD Code for a New Patient Problem Focus Exam. By providing the insurance company with the ICD Code, it will allow them to deduct full or partial costs depending on the financial policies of the provider. The patient may personally contact their insurance company to inquire if they can accept the following ICD Code listed below.

ICD Code:
99201

Additional Reimbursement Options:
At the time of the naturopathic visit, NHCC will provide each patient with an itemized receipt of the services rendered, which the patient can provide to their insurance company for full or partial reimbursement. If there are any additional inquiries or questions involving insurance or coverage or about our licensed naturopathic physicians, please contact the NHCC office directly!