Rebecca Bitzer, M.S., R.D. & Associates, Inc. ("RBA") has implemented policies and procedures so that the confidentiality of your personal and medical information remains confidential. RBA requires your consent to use and disclose your protected health information to carry out treatment, payment and health care operations. If you would like a more detailed description of such uses and disclosures, please refer to our 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 RBA may change from time to time. You can get a copy of our revised Notice of Privacy Practices by contacting our office at 301-474-2499. We will also post a copy of our current Notice of Privacy Practices in our office.
You have the right to revoke this consent in writing at any time, except to the extent that the use or disclosure has been made prior to your revocation and RBA has acted in reliance on your consent.
Further, you acknowledge that you have an opportunity to discuss with the Registered Dietitian and/or with other office personnel, the nature and purpose of medical nutrition therapy. You understand the results are not guaranteed. You give RBA permission to send a summary note to your physician or referring doctor of the consultation here.
By signing below, you hereby consent to our use of your protected health information for treatment, payment and health care operations and acknowledge receipt of a copy of this Consent, if requested. You hereby release RBA from any legal responsibility or liability for disclosure that may arise as a result of the use or release of the information contained in your protected health information.