I,

have chosen to be a private pay client. This means that at the time of service I will be paying by cash, check, or credit card. I understand that due to this cash payment, I am receiving a discount. BeFueled Sports Nutrition will not bill insurance for services provided under this arrangement. No forms will be produced now, or in the future, for you or us to submit for insurance billing.

I agree to: 1) pay at the time of service, and 2) waive insurance billing by BeFueled Sports Nutrition 3) notify BeFueled Sports Nutrition of a desire to change this agreement prior to private payment for a session

Further, I attest that I do not have Medicaid for insurance purposes, as Federal law disallows Medicaid clients from paying out of pocket for these services.