Adult Consent Form - To Practices and Procedures of Anne Till Consulting LLC
Welcome to our practice and thank you for entrusting us with your care. The dietitians at Anne Till Consulting LLC provides nutritional and dietary counseling services to children, adolescents, and adults. Our dietitians are licensed to provide dietary and nutritional counseling by the state of North Carolina. This document contains important information about our professional services and business policies. To avoid misunderstandings, it is important that you read these policies carefully, ask for clarification if needed and after reading this, sign and date this form.
WHAT TO EXPECT: Our first few sessions will involve an evaluation of your needs (Please refer to our document on Nutrition Care Services and Fees for more details on what to expect at each consultation and what to bring to your first appointment). At your first appointment, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. Once nutritional counseling has begun, we will usually schedule weekly or bi-weekly sessions. If, at any time, you feel dissatisfied with our sessions, please let us know, so we can discuss your needs and modify our approach as needed or direct you to alternate resources that may be helpful. We would like to offer support and guidance in all the phases of our work together, including when you decide to leave counseling. The notice allows you to highlight your progress, review useful concepts and tools, and have a positive experience of completion.
IF YOU ARE PAYING OUT OF POCKET
FEES AND PAYMENT FOR SERVICES:
Initial Consultation Adults and Children (90 -120 minutes) $260.00
Second Consultation Adults and Children (60-90 minutes) $155.00
Follow up Sessions Adults and Children (45-60 minutes) $ 100.00
Nutrition Care Plan Forumulation Fee
By signing this form you are agreeing to pay the one time fee of $65 for the creation of your individualized nutrition care plan. Payment for your nutrition care plan is due at the time of your initial consultation unless you are paying out of pocket. The fee for the nutrition care plan for patients paying out of pocket has been distributed amongst the initial and the second consultation fees.
We accept checks, payable to Anne Till Consulting LLC and major credit cards including MasterCard and Visa. Receipts for our services are made upon request. Please note that fees are usually increased annually to compensate for our overhead expenses.
By signing this form you are indicating that you understand that payment for the service above is due in full at the time of your initial session.
Full Fee for Session *Please see cancellation policy below*
Questions about fees and payments should be discussed prior to or at the beginning of your appointment. Fees for phone sessions and missed appointments should be mailed to the address above, or you may bring it to your next session if one is scheduled within the next 7 days. A 10% late fee will be assessed monthly on any unpaid balance of 30 days or more.
Fees are subject to change with a 30-day in office and web site notice.
Payment is due at the time of your session. We accept checks, payable to Anne Till Consulting LLC and major credit cards including MasterCard and Visa. Receipts for our services are made upon request. Please note that fees are usually increased annually to compensate for our overhead expenses.
By signing this form you are indicating that you understand that payment for the services above is due in full at the time of each session.
INSURANCE REIMBURSEMENT: Please note that Anne Till Consulting LLC dietitians/nutritionists are currently contracted with BCBSNC, United Health Care, Aetna, Cigna, and Medcost. We will file claims for these health insurance companies, however, you will remain responsible for all co-pays and deductibles as applicable and as prescribed by your specific plan. We will verify your benefits with your health insurance (if you are a member of the companies that we are in-network with). If you are with other insurance plans it is necessary for you to verify what benefits are available to you before receiving services from Anne Till Consulting LLC. For all Health Insurance Companies that we are not in-network with - we are a fee-for-service practice, where payment is due in full at the time of your session. You may however still receive reimbursement from your insurance company for services rendered by us as an out-of-network provider, so as a courtesy, we will gladly provide you with a detailed statement at your request.
By signing this form you are indicating that you understand that Anne Till Consulting LLC will only file health insurance claims with the following health insurance companies: BCBSNC, United Health Care, Aetna,Medcost and Cigna. If you have health insurance benefits with another health insurance company and you wish to receive reimbursement for services, you must file claims directly to your insurance company.
By signing this form you are indicating that you understand that verification of benefits is not a guarantee of payment by your insurance company. Payment of benefits are subject to all terms, conditions, limitations, and exclusions of the member's contract at time of service.
CANCELLATION POLICY: Once an appointment is scheduled, that time is reserved exclusively for you. If you are unable to make the appointment, you must provide at least 24 hours advance notice so that you will not be charged the cancellation fee of $50, and so that the time may be made available to someone else. We will waive that fee in the case of emergencies (e.g., death in the family, contagious illness, unsafe driving conditions). Please note we will not make exceptions for situations such as lack of babysitter, forgotten appointment or a sudden business meeting.
If you cannot make your appointment and are unable to provide the required 24 hours notice, telehealth sessions may be used in lieu of your in-person session time to keep the continuity of treatment and to prevent you from being charged for unused appointment hours. You will need to contact the office in advance to schedule a telehealth session.
In case of inclement weather, please call the office voicemail the morning of your appointment and listen for an outgoing message regarding the office opening.
By signing this form you are indicating that you have read and understood that missed appointments or appointments not canceled at least 24 hours in advance will be charged a cancellation fee of $50.
CONTACTING YOUR DIETITIAN/ NUTRITIONIST: You can contact our office by phone at 919-990.1130 or by email at firstname.lastname@example.org. Please note that email is not a secure form of communication, and also that we have found important issues are best discussed directly during our sessions. Please keep email correspondence as far as possible to scheduling and administrative purposes.
If we are unavailable for your immediate attention, please leave a message on voice mail and we will make every effort to return your call within the day whenever possible, or by the next business day. For medical emergencies, visit your closest emergency room or call 911. If your dietitian is unavailable for an extended period of time, we will notify you and refer you to another associate, if needed.
CONFIDENTIALITY: In general, the law protects the privacy of all communications between a client and a clinician. In most situations, we can only release information about your treatment to others with written permission, but please note the exceptions listed below:
If I have cause to suspect abuse and/or neglect of a minor child, elderly or disabled, we are required to file a report with the appropriate state agency.
If we believe you present an imminent danger to the health and safety of yourself or another, we may be required to disclose information in order to take protective actions, including initiating hospitalization, warning the potential victim, if identifiable, and/or calling the police
In response to a court order or where otherwise required by law.
If a client files a complaint or lawsuit against us, we may disclose relevant information regarding that client in order to defend our practice.
To the extent necessary for emergency medical care to be rendered.
Please be aware that if you submit receipts of your sessions to your insurance company, the information on the receipt, including clinical diagnosis, will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, your dietitian/nutritionist has no control over what they do with it. In some cases, they may share the information with a national medical information databank.
Other exceptions are described in the Notice of Privacy Practices, which you will have received a copy of.
Finally, there are times when we find it beneficial to consult with colleagues as part of my practice for mutually professional consultation. The consultant is also legally bound to keep the information confidential.
*Please note that if you are also seeing another provider in the practice, we have the right to discuss pertinent information that you may disclose to us with that provider to coordinate the best possible care.
By signing this form you are indicating that you have read and understood the contact instructions and the exceptions to confidentiality.
PROFESSIONAL RECORDS: The laws and standards of our profession require that dietitians/nutritionists keep Protected Health Information (PHI) about you in your Electronic Clinical Record. It includes information about your reasons for seeking nutritional counseling, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that we receive from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in unusual circumstances that involve danger to yourself and/or others or the record makes reference to another person (unless such other person is a health care provider) and your dietitian believes that access is reasonably likely to cause substantial harm to you or another person, you may examine and/or receive a copy of your Clinical Record, if you request it in writing.
Because these are professional records, untrained readers can misinterpret them. For this reason, we recommend that you initially review them in the presence of your dietitian/nutritionist or have them forwarded to another health professional so you can discuss the contents. A separate consent form to release medical records must be authorized by the client before we can release these records. If your dietitian/nutritionist refuses your request for access to your records, you have a right of review, which your dietitian/nutritionist will discuss with you upon request.
See the Notice of Privacy Practices for additional information regarding the release of your PHI.
By signing this form you are indicating that you have read and understand the above information regarding the release of your medical information.
NO GUARANTEES. The dietitians/nutritionists at Anne Till Consulting LLC are committed to providing good care to their clients. It is important nonetheless to recognize, that the success of treatments provided by our dietitians/nutritionists will depend on your own efforts and that there are no guarantees or assurances that suggest that nutritional counseling and lifestyle intervention techniques will be successful. It is important to understand that to maintain healthy outcomes that recommended interventions and methods may need to be applied over a lifetime to ensure long-term success.
By signing this form you are indicating that you have read and understood the above information regarding the no guarantees. And that you are aware that medical nutrition therapy is not an exact science, and acknowledge that no guarantees have been made to you as to the results of nutritional counseling.