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Benton Functional Nutrition, LLC Disclosure Statement Welcome to Benton Functional Nutrition, LLC. Rhiannon Benton, ACN, is a practitioner of Applied Clinical Nutrition. She is not a licensed physician.

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How to fill out new patients disclosure form

01

To fill out the new patients disclosure form, follow these steps:

02

Start by providing your personal information such as your full name, date of birth, and contact details.

03

Next, enter your medical history, including any pre-existing conditions, allergies, or previous surgeries.

04

Answer the questionnaire regarding your current health status, such as any symptoms or medications you are currently taking.

05

Provide your insurance information, including the policy number and any primary or secondary insurance plans you have.

06

Review the form to ensure all the information you provided is accurate and complete.

07

Sign and date the form to acknowledge that the information you provided is true and accurate.

08

Submit the form to the designated recipient, whether it's your healthcare provider or the hospital's administrative department.

Who needs new patients disclosure form?

01

Anyone who is a new patient seeking medical care or treatment needs to fill out the new patients disclosure form. This form collects essential information about the patient's medical history, current health status, and insurance coverage. It helps healthcare providers better understand the patient's needs and provide appropriate care. Both adults and minors who are new patients will typically be required to complete this form.

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What is new patients disclosure form?

The new patients disclosure form is a document that healthcare providers must complete to provide essential information about their practice and to ensure transparency regarding patient treatment.

Who is required to file new patients disclosure form?

Healthcare providers who are seeing new patients, particularly those participating in certain health programs or insurance plans, are required to file the new patients disclosure form.

How to fill out new patients disclosure form?

To fill out the new patients disclosure form, obtain the form from the relevant healthcare authority, provide accurate information about your practice, including credentials, services offered, and any financial arrangements, then submit it as instructed.

What is the purpose of new patients disclosure form?

The purpose of the new patients disclosure form is to ensure that patients have access to clear information about their healthcare providers and to promote transparency in healthcare practices.

What information must be reported on new patients disclosure form?

The information that must be reported includes providers' names, qualifications, types of services offered, any affiliations with insurance companies, and any potential conflicts of interest.

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