Consent for treatment, Agreement and Practice Policies

NutritionECW LLC requires your consent to use and disclose your protected health information to carry out treatment, payment and healthcare operations. If you would like a more detailed description of such uses and disclosures, please refer to our HIPPA Notice of Privacy Practices.

You have the right to review our Notice of Privacy Practices before signing this Consent. The terms of our Notice of Privacy Practices of NutritionECW LLC may change from time to time. You can get a copy of our revised Notice of Privacy Practices by contacting our office at 678-407-2159 or find it online. We will also post a copy of our current Notice of Privacy Practices in our office.

I authorize practitioners from NutritionECW, LLC to discuss, exchange and share information related to my personal health to the following names. 

2 - Consent for treatment
I have had an opportunity to discuss with the Registered Dietitian and/or with other office personnel, the nature and purpose of medical nutrition therapy. I understand the results are not guaranteed.

I give NutritionECW LLC permission to contact my physician or other healthcare provider(s) for the benefit of communicating my progress and dietitians regarding my treatment. This may include a summary note being sent to my physician or other healthcare provider(s).

 

3 - Informed Consent for Telehealth Consultations
Patients agree to participate in telehealth visits only while stationary and in a private, safe, appropriately clothes, and distraction-free environment.

• For the safety of our patients, the practice does not allow telehealth visits under the following situations:
while driving or operating any vehicle or machinery, in public settings (Stores, restaurants, cafés or any area where others can overhear sensitive information), under the influence of substances (actively intoxicated, drinking alcohol, using recreational drugs) while engaged in any activity that interferes with the quality or confidentiality of care (cooking, exercising, caring for children without support, working on a computer or taking work calls, watching TV or using other devices or around excessive noise) unstable internet connection that disrupts communication presence of unauthorized individuals. Unless the patient consents and it is clinically appropriate, others should not be in the room.

If any of the situations listed above occur during your scheduled telehealth visit, the provider may determine that the appointment cannot continue. In such cases, you may be offered a new appointment time. However, the current appointment will not proceed as scheduled because multiple reminders are provided prior to your visit, you are responsible for ensuring that you are prepared and in an appropriate setting for the appointment.

• I understand that telehealth is the use of electronic information and communication technologies by a healthcare provider for the delivery of services to an individual when he/she is located at a different site than the provider. I hereby consent NutritionECW providing healthcare services to me via telehealth.

• I understand that the laws that protect the privacy and the confidentiality of health information also apply to telehealth. Practice's telehealth services are provided by Kalix, Inc., a HIPAA compliant EMR and telehealth platform.

4 - PRACTICE Policies
• If your insurance requires a REFERRAL, it is your responsibility to obtain the proper referral prior to your visit, if needed.

INSURANCE - Under your health plan, you are financially responsible for co-payments, co-insurance and deductibles for covered services, as well as those services that exceed benefit limits. You are also financially responsible for all non-covered services as defined by your health plan contract (BIAS Body composition analysis, etc.)

• If your insurance requires a co-pay, they are due at the beginning of the appointment. We do not bill insurance for co-pays.
• Provider will file your insurance only if Provider is an approved in-network provider under your insurance plan. It is your responsibility to provide the necessary insurance information to do so, including any pre-authorizations, if necessary. If this information is not provided at or prior to the time of your visit, you will be required to make payment for services rendered at the conclusion of your visit. If Provider is not an approved provider under your insurance plan, Provider will not file your insurance, and you will be required to make payment at the conclusion of your visit.
You understand that insurance is a contract between you and your insurance carrier and does not guarantee payment for nutrition services and/or payment to Provider. Ultimately, it is your responsibility to be aware of your insurance and referral coverage.
• Each insurance plan has different guidelines as to what diagnoses are covered. We strive to stay current with all insurance coverage guidelines, but we can never guarantee coverage.

CANCELATION POLICY
• All appointments, whether in-person or virtual require a 48-hour notice to cancel/reschedule prior the day of the appointment. There is a $75.00 fee for no show up, miss or cancel with less than 48 hs of the scheduled time. This fee is charged to the patient who missed the appointment and is not the responsibility of the insurance.

FINANCIAL RESPONSIBILITY
Payment is expected at the time services are rendered.

I understand that you are obligated to ensure that our fees are paid in full. NutritionECW LLC will verify coverage and bill insurance carrier on behalf of you however, you are ultimately responsible for the payment of your bill.

You are also financially responsible for all non-covered services as defined by your health plan contract (BIAS Body composition analysis, Nutrigenomix, Food frequency questionnaire analyzed by Nutrigenomix, et

• If you have any questions regarding your insurance coverage please direct them to your insurance representative. If you fail to pay your account, you will be responsible for any collection fees incurred, including but not limited to actual attorney fees and court costs, and all other fees associated with collection.

• If your account is 90 days past due, it will be sent to a collection agency. A $25 collections fee will be issued.

We allow 30-60 days for your insurance company to make payment to us. Sometimes insurance companies request more information before they make a payment; please respond promptly to your insurance company or NutritionECW, LLC with requests for further information. If you fail to respond, you will be billed and expected to pay promptly.

Provider shall not become involved in disputes with your insurance company regarding claims, deductibles, co- payments, non-covered charges, or other denials of coverage or payment.

 

5 - CREDIT/DEBIT Card Authorization Form - Please complete all fields. You may cancel this authorization at any time by contacting us. This authorization will remain in effect until cancelled.
At your first visit, you must show the Credit/Debit card that will be stored in your record, and you authorize the saving of your card on file for future use. You can use a Health Flex Spending card or medical saving accounts at the time of the visit but NOT to be stored in your file.

All payments, co-payments, deductibles or no shows will automatically be discounted from your credit card if your insurance denies coverage. In case a refund is needed, our practice will refund it to that same credit card. You will always receive a secure email notification with a transaction receipt. This card will also be used for refunds or to void payments

We accept payment by credit card (Discover, Visa, MasterCard, American Express, Diners Club International, PayPal) and cash.

 

RECEIPT of Notice of PRIVACY PRACTICE Acknowledgement
I have read the patient policies (including payment, copayment, missed/cancelled or rescheduled appointment policy) and I read HIPAA Privacy Notice and Agreement to its terms to release information for treatment and services rendered. By signing below, I acknoeledge and agree that I have read or had this read to me and I understand and agree to its contents. I certify that all information provided is accurate and reliable.