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

 

OTHER FEES

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.

  

Late Cancellation                                      

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, and Cigna, 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 info@annetill.com. 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.

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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.

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ATC Notice of Privacy Practices

 

This document describes how we at Anne Till Consulting LLC (ATC) may use and disclose nutritional, lifestyle, medical and financial information about you (protected health information-- PHI) that is in our possession. It also describes how you can access this information. We may change our privacy practices at any time as allowed by state and federal law. If we make a significant change in those practices, we will amend this Notice and make the new Notice available on request. To request a copy of our Notice or for more information, please contact Mrs. Anne Till, MNutr, RDN, LDN of Anne Till Consulting LLC. At: 105B Kilmayne Drive, Cary, 27511

Please review this notice carefully. 

 

TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS: Federal law does not require us to obtain consent to use or disclose your PHI for treatment, payment, and health care operations. We may use or disclose your PHI to another health care professional to provide treatment to you. We may use or disclose your PHI to obtain payment for services we provide to you or to determine eligibility or coverage for services. We may also use your PHI in connection with professional performance and operation standards. This includes quality assessment, licensure and credentialing activities, training, audits, administrative services, case management, and care coordination, among other similar activities.

 

USES PURSUANT TO AN AUTHORIZATION: As permitted by federal and state law, we may disclose your PHI with your consent. You may generally revoke your consent in writing at any time to the extent we have not already relied on that consent. It is understood that such consent may authorize the release of information to which you have not had access or to information that has not been generated at the time of the execution of the release.

 

FURTHER DISCLOSURES: Federal and state law do not require patient consent for the following disclosures:

A. Child Abuse: We must report to the local Department of Social Services information that leads us to reasonably suspect child abuse or neglect. We must also comply with a request from the Director of the Department of Social Services to release records relating to child abuse or neglect investigation.

B. Adult Abuse: We must report to the local Department of Social Services information that leads us to reasonably suspect that a disabled adult is in need of protective services.

C. Judicial/Administrative Proceedings: We must comply with an appropriately issued court order or subpoena requiring that we release your PHI and with certain requests from law enforcement agencies.

D. Serious Threat to Health or Safety: We may disclose your PHI to protect you or others from a serious threat of harm.

E. Worker's Compensation: Under certain circumstances, we may disclose your PHI in connection with a Worker's Compensation claim that you have filed.

F. Appointment Reminders and Health-Related Benefits Services:  We may use your demographic PHI to contact you as a reminder that you have an appointment or to recommend possible treatment options or alternatives that may be of interest to you.

 

G. Health Oversight Activities:  We may disclose PHI to a health oversight agency for oversight activities authorized by law including audits; civil, administrative, or criminal investigations; inspections; licensure or disciplinary actions; administrative or criminal proceedings or actions; or other activities necessary for oversight of the health care system, for government benefit programs, or for administrative requirements of entities subject to government regulations. 

 

H. Specialized Government Functions: We may disclose PHI required or permitted under federal or state law.  For example, if you are a member of the Armed Forces, we may disclose PHI as required by military command authorities, national security intelligence activities, protective services for the President, and medical suitability determinations by the Department of Defense or Veterans Affairs.

 

I. Lawsuits or Disputes:  If you are involved in a lawsuit or dispute we may disclose medical information about you in response to a court or administrative order.  We may also disclose PHI in response to a subpoena or other lawful process after we have attempted to notify you about the request for the legal process.  We also have the right to release the information to our legal representatives in the event a claim or lawsuit is brought against us. 

 

J. Information Shared with Family, Friends, or Others: We may release PHI to a family member, friend, or another person you have told us is involved in your care that you want to receive PHI.  This may include PHI released to the person for payment purposes unless you object to such release in advance. 

K. As Required by Law: There may be other instances where either federal or state law requires that we release your PHI.

 

PATIENT RIGHTS:

A. You have a right to request restrictions on certain uses and disclosures of PHI; however, federal law does not require that we comply with all requests. You can request and receive confidential communications of PHI by specified means and at alternative locations.

B. You may inspect or obtain a copy of PHI in certain circumstances. You may be charged a fee for the cost of copying and delivery of your PHI.  If we deny you that right, you may have this decision reviewed. We will answer your questions concerning the details of the reviewing process.

C. You may request a correction or update to your PHI for so long as we maintain that PHI in our records. Federal law does not require us to agree to each such request. We will answer your questions about the correction process.

D. You have a right to receive an accounting of most disclosures of PHI for which you have not provided consent.  However, you are not entitled to receive an accounting of disclosures made for treatment, payment, or health care operations.  We will answer your questions concerning the accounting process.

E. You have a right to obtain a paper copy of this notice from us upon request, even if you have received this notice electronically.  All such requests must be submitted in writing to Mrs. Anne Till, Anne Till Consulting LLC. at 105B Kilmayne Drive  Cary, NC  2751. 

DIET THERAPY AND COUNSELLING NOTES:  You will need to provide us written consent for the release of diet therapy and counseling notes/records specifying the records that you want to be released, except in instances where the release of these records is required by law.  Diet therapy and nutritional counseling notes do not include prescription information, the times or duration of therapy, the frequency of treatment, clinical test results, or a clinical summary of your care that does not include the diet therapy and counseling notes.  While you have the right to request a copy of your diet therapy and counseling notes, we have the right to withhold them if we believe the release of the notes would be harmful to you.

QUESTIONS: If you have questions about this notice, disagree with a decision we make about access to your PHI or have other concerns, contact Mrs. Anne Till, MNutr, RDN, LDN, NC License # L004328 at (919) 990-1130. You may also file a complaint with the Secretary of the US Department of Health and Human Services. We can provide you with that address. You have the right to be free from retaliation from us for exercising your right to file a complaint. This policy is effective this 1st day of July 2019. You are requested but not required to sign this form.

 

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CONSENT TO USE OF EMAIL

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I {patientsFull} agree to communicate with Anne Till Consulting Dietitian and Nutritionists regarding my care, and/or that of my child via email.

I have been informed of several precautions to guard the privacy and security of personal health-related information, consistent with Federal HIPPA standards.

These precautions include:

· Communication regarding non-sensitive subject matter primarily emails regarding scheduling, may take place without encryption of the email.

· Emails may be sent bcc to notify patients of appointment opportunities

· I recognized that every effort will be made to protect my privacy

· I have been encouraged to send personal health-related information as needed using the same safeguards, which may include digital encryption.

I recognize that despite these precautions, email is not an entirely secure form of communication, and email communications may be intercepted and my privacy breached.

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