Results based on your current Body Mass Index (BMI)
and Basal Metalogic Rate (BMR)
Real weight loss begins with you. If you tried everything and are serious about weight loss,
taking control and regaining your health then
Please complete the following Nu Beginnings admission questionnaire as best as possible. Spending the time to complete our easy questionnaire will make your office visit nearly hassle free.
The Nu Beginnings program may be covered by medical insurance, if certain qualifications are met. When you have completed the form, please click on the submit button below and an intake coordinator will contact you within one business day to arrange your free initial consultation. We look forward to helping you with your journey!
Required: Please give us all pertinent information regarding your insurance coverage. If you have coverage by more than one carrier, supply information of all.
Required: In order to submit a claim for payment to us for services covered under you policy, we must have your authorization to release medical information to your insurance carrier.
Medicare and Medicaid: I certify that the information given by me in applying for payment under Title XVIII of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration or its intermediaries or carriers any information needed for this or a related Medicare claim. I request that payment of authorized benefits be made on my behalf. I assign the benefits payable for physician services to the physician or organization furnishing the services or authorize such physician or organization to submit a claim to Medicare for payment to me. I request that payment under the medical insurance program be made either to me or to Texas Spine Institute or Synergy Health Group on any bills for services furnished me by Nu Beginnings during the next 12 month period.
All Other Insurance: I hereby authorize Nu Beginnings to submit a claim to my insurance carrier or its intermediaries for all covered services rendered by the physician(s) and authorize and direct my insurance carrier or its intermediaries regarding services rendered.
Payment Default: In the event of payment default, I agree to be responsible for any and all collection fees.