RBA 2022 Registration Forms

Registration Forms
First Name*
Middle Name
Last Name*
Home Phone Number*
Address*

Home Address

Street Address Line 2

CityState

Zip Code
Occupation
Relationship Status
Date of Birth*

MonthDayYear
Date
Age
Gender
Pronouns
E mail address
example@example.com
Work Phone Number
Employer
Employer Address
Employer Phone Number
Partner (or parent) employer
Partner (or parent) employer
Partner (or parent) Phone Number
Family Physician
Address
Family Physician Phone Number
Referring Physician
Referring Physician Address
Referring Physician Phone Number
How did you hear about us?
BILLING AND INSURANCE INFORMATION
Insurance Company Name*
Member ID or Policy Number*
Group / Enrollment Code
Subscriber's Name
Date Effective

MonthDayYear
Date
Subscriber's Date of Birth

MonthDayYear
Date
Sex
Home Phone Number
Relationship to Patient
Do you have any other Insurance?

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A message can be left on my home phone or cell phone. Please select one option.*

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PRIVACY CONSENT

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.
Printed First and Last Name*
Signature*

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Date*

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Policies

Thank you for choosing Rebecca Bitzer, M.S., R.D. & Associates, Inc. ("RBA" Medical Nutrition Therapy ("MNT") is covered by many insurance plans. By signing below, you agree to these terms. We will use your insurance benefits when possible. MNT is defined as face-to-face medically necessary nutrition counseling. We will also provide additional non-covered services when necessary to help you meet your nutrition goals. Here are our billing terms:
1. If using health insurance benefits:
  - You hereby authorize RBA to apply for benefits on your behalf for covered services rendered. You certify that all information given to RBA is correct, and authorize the filing of claims and release of all information, including medical information for this or related claims. You authorize RBA to share information about you and your treatments for payment processing and as otherwise provided in our Privacy Notice. Further, you authorize RBA to receive benefits when a claim is filed, to appeal any denials and to otherwise deal directly with your insurance company.
  - If required by your insurance, it is your responsibility to bring a proper referral (and/or obtain any required pre-authorization) and copay to your appointment.
  - You understand that RBA may verify your benefits prior to your appointment, however, that is not a guarantee of coverage and it is ultimately your responsibility to be aware of your coverage, limitation and exclusions before the time of service. You understand that if your insurance company does not cover MNT for any reason (including a lack of any needed referral or pre- authorization), you will be responsible for all non-covered services rendered. If RBA is uncertain of coverage, RBA will keep a deposit or credit card on file until it is compensated by the insurance company.
2. All fees are due at the time of service or when invoiced. Patients must have a zero balance in order to be seen. Additional fees may apply, including the following:
  - There will be a $25 fee for any returned checks.
  - RBA has a policy for missed or cancelled appointments. Cancellations or missed appointments with less than 24 hours will be charged a $40 fee. Please cancel your appointment before 3 pm the day before your scheduled appointment in order to avoid being charged this fee.
    
    After the third late cancellation or no show, the penalty charge will be the cost of a full session which is $140.
  - There will be a penalty of losing your recurring appointment spots if you cancel/reschedule more than 2 times a month.
  - There will be a 15% fee added to any outstanding balances that are 30 days overdue, 30% added to any outstanding balances that are 60 days past due and 45% to any outstanding balances that are 90 days past due. Any outstanding balances after 90 days may be referred to an outside collection agency. Patients with continually delinquent accounts or those whose accounts have been sent to a collection agency are subject to discharge from RBA. If any of RBA's directors, officers, employees or stockholders are asked to be involved in any legal matter requiring participation pertaining to you or your child via telephone, court deposition and/or court appearance, RBA will charge a fee for those services. This will include preparation time, professional time and transportation costs. The fee for these services of two hundred fifty dollars ($250.00) per hour will be billed to the patient whose attorney is requesting the information.
3. Self-Pay Services:
  - RBA has discounted, prompt pay fees available. These services are available to you if your insurance does not cover your nutrition counseling or if your Registered Dietitian Nutritionist advises non-covered services. The self-pay services are as follows:
    
    Nutrition Counseling either in person or via telehealth:
    
    Basic Self-Pay Packages (SPP):
    
    Initial session ($185)
    
    3 Visit Self Pay Package ($400)
    
    3 Visit Couples Self Pay Package ($600)
    
    Other non-covered services but not limited to:
    
    Daily Remote Monitoring $250/month
    
    Eating disorder Coordination of Care Fee $75/session
    
    Phone call with dietitian $25
    
    Customized Meal Plans $250
    
    Medical Records $25
    
    Note: Prices for these services do change periodically, please check with our administrative team for an updated price list.
    
    Testing:
    
    RMR Metabolism Testing
    
    Body Composition Analysis
    
    Food Sensitivity Testing
    
    Micronutrients Testing
    
    Stool Testing
4. Nutrition Disclaimer and Acknowledgement: You understand that RBA provides dietitian and nutritional services as Registered Dietitians, and not medical physicians. You further acknowledge and agree that RBA does not, and will not, dispense medical advice or diagnose or treat any medical conditions, but rather, will exclusively provide nutritional support and nutrition education for conditions diagnosed by a third-party medical professional.
5. Food Allergies/Sensitivities: You acknowledge and agree that specific foods may create allergic and possible fatal reactions, for example, but without limitation, products containing nuts. You hereby agree to disclose any food allergies/sensitivities that you are aware of. You are aware that specific foods may interact with certain medications. You have discussed the side effects of all of your medications with your doctor or pharmacist. You hereby release RBA, its directors, officers, employees and stockholders from any legal responsibility or liability for recommending or providing certain foods after relying on your disclosure of known food allergies/sensitivities.
6. Supplements: You acknowledge and agree that any advice regarding dietary supplements provided by RBA is strictly done so by opinion only, and these products may not have been approved by the FDA. You acknowledge that any companies or products mentioned by RBA are not affiliated with RBA and RBA, its directors, officers, employees and stockholders are not liable for any claims relating or arising therefrom.
7. RBA reserves the right to change these terms at any time. You may obtain a revised copy of these terms by submitting a written request to our office, by emailing us or by requesting in person at our office.
8. How We Will Communicate With You:
Use of Telephone:

If you provide us with a telephone number, we may contact you using that telephone number to discuss your services, appointments, records, and purchases.

Use of Electronic Communication Methods:

Electronic communications include email messages, internet communication services (such as Skype™), or other electronic methods. You agree that electronic communications are not secure and that there is the possibility that they may be accessed by other persons. You also agree that your employer may review any electronic communications transmitted through your employer's computer system. We may use email or other electronic communications to transmit routine information to you (such as appointment dates, newsletters, etc We may also use email or other electronic communications to transmit information concerning your services and products, unless you tell us otherwise (as described below If you give us an email address or communicate with us using other electronic communications, you agree that: (a) electronic communications should not be used for emergency or other time-sensitive situations or where sensitive information will be transmitted (please contact us by telephone or visit our location); (b) we will use reasonable efforts to respond to electronic communications that you send (if you do not hear from us within 2 business days, please contact us by telephone or visit our location) and we will not be liable for any failure to respond or any intercepted electronic communications; (c) one or more of our staff members may need to access your electronic communications in order to help us respond; and (d) we may keep copies of electronic communications that you send in your patient records.

If you do not wish us to use electronic communications to transmit information concerning your services/products, you can provide written notice to us at admin@rbitzer.com or at 301-474-2499.

You acknowledge and agree that you accept all of the above terms in the Policies.
Signature*

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Date*

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Front of Insurance Card
Back of Insurance Card
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Credit Card Payment Authorization
Please sign below to authorize Rebecca Bitzer, M.S., R.D. and Associates, Inc. to use this credit card for fees and charges related to your RBA services/products. Your authorization will remain in effect until you cancel it by calling us at 301-474-2499 or emailing us at admin@rbitzer.com.

Disclaimer: You will not be charged the $0.01 once you input your card. Stripe makes it mandatory to input a charge amount but you will not be charged.

I, authorize RBA to use the credit card I provided, to pay for services, products or other fees. I understand that I am financially responsible for all charges for services rendered on my behalf or on behalf of my dependent.

$0.01

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Authorization Signature

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Date

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Food Questionnaire
What are your favorite foods
What are your least foods
How many times PER WEEK do you eat the following meals out? (fast food, take out, restaurants)
Breakfast
Lunch
Dinner
Do you avoid any foods? Why?
Alcohol/ Drug Consumption?
Please record what you ate and drank yesterday
Breakfast (Time, Food eaten or a description, Location of where you ate)
Lunch (Time, Food eaten or a description, Location of where you ate)
Dinner (Time, Food eaten or a description, Location of where you ate)
Snacks (Time, Food eaten or a description, Location of where you ate)

AUTHORIZATION TO OBTAIN/RELEASE CONFIDENTIAL INFORMATION
I, __________________authorize Rebecca Bitzer, M.S., R.D. and Associates, Inc. to
- Discuss my treatment progress
- To obtain medical records and/or progress notes
- To release medical records and/or progress notes
With/To/From the following individuals:
Patient Name
Primary Doctor Name
Primary Doctor Address
Primary Doctor Phone Number
Primary Doctor Email
example@example.com
Therapist Name
Therapist Address
Therapist Phone Number
Therapist Email
example@example.com
Treatment Center Name
Treatment Center Address
Treatment Center Phone
Treatment Center Email
example@example.com
Other Physician Name
Other Physician Address
Other Physician Phone Number
Other Physician Email
example@example.com
Other Physician Name
Other Physician Address
Other Physician Phone
Other Physician Email
example@example.com
I understand that my records and treatment are confidential and will not be disclosed without my written consent unless under legal compulsion. I agree that RBA is not responsible for any action or adverse consequence related to the release of this information and is not required to verify the validity of the information above. I 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 the protected health information. I also understand that I may revoke this consent in writing at any time, except to the extent that action has been made prior to the revocation and in reliance therein.
Date

MonthDayYear
Date
Patient Signature

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Patient Address
Parent/Guardian Signature

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Dietitian Signature

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Authorization and Consent to Treat Minor Child

I, ____________________[Full Legal Name of Parent/Guardian], being the parent/legal guardian of ____________________[Child’s Full Name] authorize ____________________[Full Name of Caregiver] to seek, obtain and consent to [routine medical care and treatment/emergency medical care and treatment/ surgery/hospitalization/blood transfusions/dental care and treatment/other] for ____________________[Child’s Full Name] as deemed necessary by a licensed medical or healthcare professional. This authorization is for the time period when my child is in the care of ____________________[Full Name of Caregiver], my child’s ____________________[Relationship to Child (e.g. grandmother, grandfather, aunt, uncle, nanny, baby-sitter, family friend, teacher)] and is effective during such period as I may for any reason not be available to give my consent to any treatment for my child.
Child's Full Name
Address
Date of Birth

MonthDayYear
Date
Age
Parent's/Guardian's Name 1
Address
Phone Number (Home)
Phone Number (Cell)
Email Address
example@example.com
Parent's/Guardian's Name 2
Address
Phone Number (Home)
Phone Number (Cell)
Email Address
example@example.com
Child's Health Information
Health Condition (e.g. Asthma, Diabetes):
Allergies (e.g. to Medications, Food):
Prescription Medication
Date of Last Tetanus Injection/Booster

MonthDayYear
Date
Child's Medical Care and Insurance Information
Physician/Pediatrician
Phone Number
Dentist/Orthodontist
Phone Number
Preferred Medical Facility
Insurance Company
Policy/Group Number
Policy Holder
Executed on:

MonthDayYear
Date
Witness
Signature of Parent/Guardian

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Witness
Signature of Parent/Guardian

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Should be Empty:

Registration Forms

Credit Card Payment Authorization

List all Medications You Currently Take Regularly OR as Needed

Nutrition Assessment

Food Questionnaire

AUTHORIZATION TO OBTAIN/RELEASE CONFIDENTIAL INFORMATION

Child's Health Information