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.
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.
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.
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.
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.