CRT Patient Form – My Nutrition

Cardiorenal Therapeutics

Terms & Conditions For and in consideration of the services rendered by CARDIORENAL THERAPEUTICS, I agree to pay said provider of services for all services needed. I understand that I am responsible for all health insurance deductibles, co-payments and coinsurance charges not covered by my insurance policy to include but not limited to charges for service, experimental investigation and/or not medically necessary as determined by my insurance company. In consideration of services rendered, I hereby transfer and assign CARDIORENAL THERAPEUTICS all rights, title, and interest in any payments due to me for services described herein as provided in the above-mentioned policies of insurance or settlements or judgments. I hereby consent to the release of information necessary to process claims with my insurance company. I understand that the person giving authorization may revoke this authorization by a written and dated notice except to the extent that disclosure of information that has been made prior to the receipt of the revocation. I have read and understand this consent and I have signed it voluntarily and of my own free will.
Signature of Patient/Representative (Electronically Signed) *
Date *