PATIENT’S RESPONSIBILITY FOR PAYMENT
I am a member of the health insurance plan entered below. My plan may or will only provide payment
for certain covered medical services. I have requested that Elaine Roach LD/N, MPH provide Medical
Nutrition Therapy services which my health insurance plan may not pay for (Deductibles, Member portion,
Out-of-pocket, termination of coverage etc.). I agree that I am financially responsible for these services.
Agreement: I understand that this facility Wellness 4 Life, LLC., and its practicing Dietitian/Nutritionist
standard procedure is to bill patients for any non-covered or denied services. If I do not pay for these
services within 60 days from the date of service, I agree and permit Wellness 4 Life LLC to pursue these
charges through a collection agency or take further action.
This is a legal document which can and will be enforced in a court of law.
Florida Statute: Chapter 559 Section 55