NOTICE OF PRIVACY PRACTICES & CONSENT TO TREATMENT

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE READ AND REVIEW IT CAREFULLY.

The Health Insurance Portability & Accountability Act of 1996 (HIPAA) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential. In general, the HIPAA Act gives you, the client or patient, significant new rights to understand and control how your health care information is used. HIPAA provides penalties for covered entities that misuse personal health information.

As required by HIPAA, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information.

We may use and disclose your medical records only for each of the following purposes: treatment, payment and healthcare operations.

Treatment means providing, coordinating, or managing health care and related services by one or more health care providers. An example of this would be performing nutrition counseling in this office, or making a referral to another health care provider for additional evaluation or treatment.

Payment means such activities as obtaining reimbursement services, confirming insurance coverage, billing or collection activities, and utilization review for managed care coverage and approval and/or at the request of a third party payer for your treatment (your insurance company). An example of this would be sending a bill for your nutrition visit to your insurance company, or telephonically, by mail, or by fax, sending the necessary clinical information for your insurance company to approve more sessions for coverage for you.

Health care operations include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis, and customer service. An example would be an internal quality assessment review.

We may also create and distribute de-identified health information by removing all references to any and all individually identifiable information. We may contact you to provide appointment reminders or information about treatment alternatives or other health related benefits and services that might be requested by or be of interest to you.

Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your prior written authorization to take such actions.

You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to your dietitian. The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. We are, however, not required to agree to a requested restriction if Vermont law or Federal law indicates that to do so would be a violation of Duty to Warn Statutes of person or property, violation of mandated reporting of known abuse of a minor or child, or violation of mandated reporting of known abuse of an elderly or incapacitated person. As a nutrition client/patient you own the privilege of confidentiality, and no information, including your presence in therapy or the fact that you are a patient, will be disclosed without your specific written permission in a release of information request. HIPAA regulations do not affect any previous safeguards to your privacy as a patient, except in certain cases to strengthen them.

The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternate locations.
The right to inspect and copy your protected health information.
The right to amend your protected health information.
The right to receive an accounting of disclosures of protected health information.
The right to obtain a paper copy of this notice from us upon request.

We are required by law to maintain the privacy of your protected heath information and to provide you with notice of our legal duties and privacy practices with respect to protected health information.

This notice is effective as of November 1, 2011 and we are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to change the terms of our Notice of Privacy Practices and to make the new notice provisions effective for all protected health information that we maintain. We will post and you may request a written copy of a revised Notice of Privacy Practices from this office.

You have recourse if you feel that your privacy protections have been violated. You have the right to file written complaint with our office, the Department of Health and Human Services, or the Office of Civil Rights, about violations of the provisions of this notice or the policies and procedures of our office. We will not retaliate against you in any fashion for filing a complaint.

Please contact us at 802-999-9207 Whole Health Nutrition, LLC for more information.

Disclosure Statement

The Purpose of Nutrition Therapy:

Nutrition intervention is a vital component to primary prevention and treatment of many health issues. Many health care providers recognize this and make referrals to a Registered Dietitian for implementation of a nutrition prescription. A Registered Dietitian has the training and expertise to tailor a diet to an individual's eating habits, lifestyle and nutrient needs.

Methods and Duration of Treatment:

Whether the work is to restore nutritional health, improve one’s relationship with food, improve athletic performance, or treat and prevent disease our approach always remains client centered. We work collaboratively with patients to set goals that move them in the direction of good self-care as reflected by feeding one’s self in a way that is healthy and enjoyable. Specific methods may include meal planning, full nutritional assessment of needs vs intake, supportive eating, and assistance in shopping, accessing support, and providing nutrition education.

Supervision:

In order to offer the highest quality of service possible, we occasionally seek supervision and/or consultation from registered dietitians in our practice group and continue to pursue training in specialty areas.

Confidentiality:

Information disclosed in nutrition therapy is confidential. There may be times when we decide it would be helpful for us to speak to someone else about your treatment, such as a physician. In these instances, information may be disclosed if you give us permission in writing to do so by completing a consent form. The limits to confidentiality are the following: If you are using insurance, some insurance companies require treatment plans and diagnostic information before payment will be made.

Appointments and Cancellations:

It is important that you arrive on time. If you are late, you will be unable to use your full appointment. We will wait 15 minutes for a late client, but will feel free to leave if we have not heard from you by then.

Our cancellation policy is as follows:

*Please notify us by voice mail at least 24 hours in advance if you are unable to keep your scheduled appointment. If you can give more time than that, this is appreciated.

*Notification at least 24 hours in advance of your appointment will result in no charge for the appointment.

*Notification less than 24 hours in advance of your appointment will result in a charge for the full session fee which will be billed directly to you, the client. Most insurances will not pay for missed or cancelled appointments. Payment will be expected by the next scheduled appointment unless we make other arrangements.

We do accept some, but not all, insurances. If you are unsure about whether or not we accept your health insurance, please contact your insurance company directly. Plans often vary in their coverage for nutritional services. If your insurance plan changes, you are responsible to notify us of that change. If you do not notify us and either we do not take your insurance or am not able to receive reimbursement from your insurance company for any reason this will result in a charge to you of our full fee.

We accept BCBS, MVP, Cigna, VT Medicaid, Medicare, and United Health Care. Tricare does not provide nutrition coverage so we do not accept this insurance.

Please feel free to discuss payment questions or problems with us if you anticipate any difficulties. Should collection action ever be necessary we reserve the right to use a collection agency and/or pursue traditional court assisted collection methods. If this is necessary you will be responsible for any attorney fees and court costs.

Information concerning unprofessional conduct for this profession can be found on http://vtprofessionals.org/

Consent to treatment and confirmation of receipt of Disclosure Statement & HIPAA

I consent to treatment with this clinician. I agree to pay fees at the time of service, unless other arrangements have been made, and I will abide by the policies regarding fees and cancellations. This agreement will remain in effect until services have terminated and all payments for rendered services have been made. A photocopy of this agreement is valid. I have been given notification of the professional qualification and experience of Whole Health Nutrition, LLC a description of federal HIPAA requirements for medical records, a listing of actions that constitute unprofessional conduct according to Vermont statutes, and the method for making a consumer inquiry or filing a complaint with the Office of Professional Regulation. I agree to provide co-pay (in cash or check) at time of service. All overdue accounts (30 days) will be charged 1% interest per month (12% annually) and there will be a $30 fee for all returned checks.

Insurance Intake

Legal Name

First Name

Last Name

Preferred Name

First Name

Last Name

Affirming Pronouns

Example: she/her

Sex Assigned at Birth

Example: female

Gender Identity

Example: cisgender female

Date of Birth

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Preferred Phone Number

(###)

###

####

Okay to leave a message on phone?

YES

NO

Please list your Primary Care Provider or Referring Provider

May we thank this person?

YES

NO

Insurance Company

Insurance ID Number

Insured Person's Name

Insured person's address if different from your own:

Do you have a secondary insurance?

YES

NO

If yes, please provide your ID number and insuance company name below:

Emergency Contact:

First Name

Last Name

Emergency Contact Phone:

(###)

###

####

Signature: I hereby consent and authorize to have this therapist/agency make any and all insurance claims on my/our behalf. I understand that all questions concerning insurance reimbursement and financial responsibility are to be discussed with my therapist.

First Name

Last Name

Permission for Electronic Communication

Whole Health Nutrition (WHNvt) would like to contact you via email and/or text messaging using your personal phone regarding appointment reminders. Some limited personal information may be included; however no medical information will be specified. Select below if you wish to be contacted via text messaging and/or email.

Permission to contact via text:

YES

NO

Permission to contact via email:

YES

NO

Name

First Name

Last Name

Email

Do you wish to receive recipes, nutrition tips, and tools to support a healthy lifestyle via our newsletter?

YES

NO

Nutrition & Medical History Questionnaire

Please complete to the best of your ability prior to your initial consultation.

Name

First Name

Last Name

Email

Reason for your appointment

Is there anyone involved in your care with whom we may share your medical information?

Please list names and contact information if available.

How did you hear about us?

Returning patient

Television/Radio

Doctor’s referral

Newspaper Ad

Spouse/Family Member

Web Search/Internet

Coworker

Other - please list below

Date of your last nutrition assessment/RD evaluation

MM

DD

YYYY

List any additional health information that you feel is relevant to today’s visit:

List any medications or supplements you are currently taking:

Your narrative:

Please write a brief summary of any things else that will be helpful to us regarding your health and medical history. What is your food story, your fitness goals, your wildest dreams about health and wellness: