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NEW PATIENT INATAKE FORM

Intake Questions:

Contact Us: Contact
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Looking to start services? Send us an inquiry to start your intake process! Please only send one inquiry. The office will contact you within 24-48 business hours once your information has been processed. All other inquiries please send an email, information is below.

 

*Please note: we do receive a high volume of calls and inquiries. Calls are returned within 48 business hours, but a detailed voicemail MUST be left for a call back. 

 

*Please note: All information is required as part of our intake process. If insurance has termed or changed we cannot proceed with the intake process. Authorizations and referrals must be valid and match your current active insurance plan.

 

*Please note:Your physician MUST send us your medical diagnosis code(s) or insurance cannot be billed and you will be responsible for ALL costs. ALL sessions MUST be in person ONLY. 

 

*Please note:Any new patients with a history of an eating disorder or current eating disorder will be required to do a phone consultation with the intake manager. 

 

*Please note: if you have multiple health insurance plans and do not provide all insurances, your insurance changes, or your insurance is terminated you may be responsible for any services not covered by your insurance. This can cause lapse or termination of sessions.  Changing providers can cause change in insurance plans and changing providers or insurances at any time requres new authorization and referrals. The office MUST be notified immediately.

Intake Questions:

Tap to upload

Looking to start services? Send us an inquiry to start your intake process! Please only send one inquiry. The office will contact you within 24-48 business hours once your information has been processed. All other inquiries please send an email, information is below.

*Please note: we do receive a high volume of calls and inquiries. Calls are returned within 48 business hours, but a detailed voicemail MUST be left for a call back. 

*Please note: All information is required as part of our intake process. If insurance has termed or changed we cannot proceed with the intake process. Authorizations and referrals must be valid and match your current active insurance plan.

*Please note:Your physician MUST send us your medical diagnosis code(s) or insurance cannot be billed and you will be responsible for ALL costs. ALL sessions MUST be in person ONLY. 

*Please note:Any new patients with a history of an eating disorder or current eating disorder will be required to do a phone consultation with the intake manager. 

*Please note: if you have multiple health insurance plans and do not provide all insurances, your insurance changes, or your insurance is terminated you may be responsible for any services not covered by your insurance. This can cause lapse or termination of sessions.  Changing providers can cause change in insurance plans and changing providers or insurances at any time requres new authorization and referrals. The office MUST be notified immediately.

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©2025 by Bamboo Nutrition Therapy, Inc.     Administrative Office Phone: (323) 391-7262

Fax: (888) 977-1259

Email: admin@bamboonutrition.com

Mon~Fri:9:00am to 5:00pm

Closed on Sat,Sun and all federal holidays

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