Nutrition Programs Intake Form
Full name
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First Name
Last Name
Date of birth
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Month
-
Day
Year
Date
Your height
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Your weight
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Gender
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Female
Male
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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Please enter a valid phone number.
Email
*
example@example.com
Consent to be contacted via text message and/or email
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I consent to be contacted for appointments via text message and email.
Race
*
American Indian or Alaska Native
Asian
Black
Hispanic, Latino, or Spanish Origin
Middle Eastern or North African
Native Hawaiian/Other Pacific Islander
White
Other
Ethnicity
*
Hispanic or Latino
Not Hispanic or Latino
Primary Care Information
Bethesda NEWtrition and Wellness Solutions will be notifying your Primary Care Provider that you will be receiving services for Diabetes Self-Management Education/Training and Medical Nutrition Therapy. This is so your health care team can provide the best continuation of care services and since many insurance companies require an additional referral from your health care provider. If you have an endocrinologist or different provider that manages your diabetes, the referral will need to come from them.
Do you have a primary care provider?
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Yes
No
Name of primary care provider
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First Name
Last Name
Primary care provider - Phone number
*
Please enter a valid phone number.
Primary care provider - Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary care provider - Fax number
*
Please enter a valid phone number.
Do you have any other provider that manages your diabetes care? (Diabetes Specialist, Endocrinologist, etc.)
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Yes
No
Provider Name - specify type of provider (Diabetes Specialist, Endocrinologist, etc.). N/A if none.
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First Name
Last Name
Provider's Phone Number. N/A if none.
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Provider's Address. N/A if none.
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Provider's Fax Number. N/A if none.
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Have you seen a nutritionist/dietitian or diabetes educator since you have been a Medicare beneficiary?
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Yes
No
I am not a Medicare Beneficiary
Primary Insurance
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Primary Insurance - Policy Number
*
Primary Insurance - Group Number
*
Primary Insurance - Address (Back of Card)
*
Primary Insurance - Phone number (Back of Card)
*
Please enter a valid phone number.
Primary Insurance - Subscriber Name
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First Name
Last Name
Primary Insurance - Subscriber Date of Birth
*
-
Month
-
Day
Year
Date
Primary Insurance - Subscriber Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Type a question
Type option 1
Type option 2
Type option 3
Type option 4
Primary Insurance - Relationship to Subscriber
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Self
Spouse
Child
Other
Secondary insurance?
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Yes
No
Consent to Evaluation, Treatment, and Policies.
HIPAA Notice of Privacy Practices: The confidentiality of your personal health information is very important to us. Your health information includes records that we create and obtain when we provide you care. It includes a records of your symptoms, examination and test results, diagnoses, treatment and referrals for further care. It also includes bills, insurance claims, or other payment information related to your care. We may use and disclose your health information for your treatment and to provide you with treatment-related health care services. For example: we may disclose your health information to doctors, nurses, technicians, or other personnel, including people outside our office who are involved in your medical care and need the information to provide you with treatment.
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I understand and accept this notice.
We have chosen to participate in Chesapeake Regional Information System for our Patients (CRISP), the state-designated health information exchange for Maryland. As permitted by law, your information will be shared with this exchange to provide faster access, better coordination of care, and improved knowledge for providers. You may choose to not have your information shared with CRISP. If you do so, we may only share with CRISP that you have opted out of the data sharing. In addition, you may "opt out" and disable all access to your health information available through CRISP by calling 1-877-952-7477 or completing and submitting an Opt-Out form to CRISP by mail, fax, or through their website at crisphealth.org. You are not able to opt-out of Public Health reporting and Controlled Dangerous Substances Information, as part of the Maryland Prescription Drug Monitoring Program (PDMP), it is available on behalf of all patients to providers by law.
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I understand and accept this notice.
Consent for DSMT and MNT for Diabetes
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I hereby consent to the assessment, education and training for my diabetes management by Bethesda NEWtrition and Wellness Solutions providers as applicable by the scope of their practice. I understand that it is my right to accept or refuse any education and training offered to me. I acknowledge and understand that no guarantee has been made to me as to the results that may be obtained from such education and training.
Disclosures: I give permission for my protected Health information to be disclosed for purposes of communicating results, findings, and care decisions to the family members and others listed below. List Name, Relationship, and Contact Number. **You may revoke or modify this specific authorization and that revocation or modification must be in writing**Your answer
Financial Policy: I authorize and consent to Bethesda NEWtrition and Wellness Solutions to bill my insurance for the DSMT and MNT services. If you are unable to keep a scheduled appointment, you must call at least 24 hours in advance. If you miss your appointment, you will be charged a $50.00 fee for a missed appointment. This fee will be billed to you and not your insurance company. If you are 15 minutes late to your appointment, your appointment will be rescheduled. You are responsible for checking with your insurance plan to determine if the services provided are covered under your insurance policy. You are responsible for paying your copay before the appointment.
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I understand and accept this policy.
I agree to the items outlined in this agreement.
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I consent
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First Name
Last Name
Today's date
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Month
-
Day
Year
Date
Signature
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