CONFIRMATION & Appointment Policy

Cancellation & Missed Appointment Policy

At MDD, Inc. our Registered Dietitians are by appointment only. A last minute cancellation or no-show is time another client could have used. If you must cancel or reschedule, please do so prior to 24 hours of your appointment time at 704-846-7105to avoid a missed appointment charge. Please do not email.


To schedule an appointment, we require a valid credit card or otherwise acceptable payment method to be kept on file.


Missed Appointment Charge:  Your account will be charged $50.00 for a no-show or last minute cancellation.


Thank you for respecting this business policy.


Insurance Disclosure Policy
Due to Health Care Reform, it is uncertain if insurance will pay for your visits with the Registered Dietitian. Please note: As per your insurance plan: the quoting of benefits is not a guarantee of payment and the client is responsible if the claim is denied.


Authorization
I hereby authorize My Diabetes Dietitian Inc. to keep my account information on file for payment and to initiate debit or charge entries on this account as amounts are owed to My Diabetes Dietitian Inc. by me.


I acknowledge that the origination of ACH or credit card transactions to my account must comply with the provisions of U.S. law. I understand that a debit or charge may be made to my bank account or credit card account periodically to pay for amounts owed.


If my bank account or credit card information listed above changes for any reason, I will notify My Diabetes Dietitian Inc. This authorization shall remain in effect for two (2) years from the originating date or until My Diabetes Dietitian Inc. has received written notification from me of its termination. In the event of returned ACH or a declined charge, my account may be charged a service fee for each occurrence.

Self-Pay
Payment due in full at time of service. Non-Insured/ Time of Service Discounted Rates: $130 Initial appointment; $100- meal plan appointment and $65 (or $100 for meal plan and follow-ups requiring physician notes) for 30 minute follow up appointments.
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Confirmation

To Confirm, Complete the form below and click Submit. ***

PLEASE NOTE:

*** By submitting this form, you are giving your authorization and indicating you understand and will abide by this Cancellation & Missed Appointment Policy as stated above. 

My Diabetes Dietitian, Inc

1315 Matthews-Mint Hill Rd. Suite B Matthews, NC 28105

704-846-7105