Permission for treatment
I hereby authorize Advanced Nutrition Therapy, LLC, their employees and consultants, to provide medical nutrition therapy which may include: nutrition assessment, plan of care and education with specific recommendations. I understand that I will be involved and engaged in my care and treatment. I understand that I have a right to consult with a physician prior to receiving services from Advanced Nutrition Therapy, LLC.
Telehealth services
I understand and agree that I may be offered telehealth services which authorizes Advanced Nutrition Therapy, LLC to use online meeting sources as well as telephone calls to provide services. Telehealth appointments are private and not recorded.
Confidentiality and Notice of Privacy Practices Acknowledgement
Medical and mental health information contained in all health records is strictly confidential and may not be released without express written permission from the patient or by a court order. Confidentiality and privacy are protected in all Advanced Nutrition Therapy, LLC business relationships to prevent the exchange of any patient specific information without permission.
I understand that, under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I have certain rights to privacy in regard to my protected health information (PHI). By signing below, I acknowledge that I have received, read and understood the Notice of Privacy Practices. Advanced Nutrition Therapy, LLC reserves the right to change the terms of its Privacy Notice. If such changes are made, I understand that the Privacy Notice will be provided to me upon request.
Financial Responsibility and Authorization to Process Insurance Claims
Patients and Clients are responsible for all charges incurred by themselves or family members for services by Advanced Nutrition Therapy, LLC.. Advanced Nutrition Therapy, LLC will file insurance claims on behalf of patients and clients; however, that I, the undersigned, have read and understand this information and authorize the release of medical and other necessary information to my insurance company to process claims for services rendered. I hereby authorize my insurance company to distribute payment of my coverage directly to Advanced Nutrition Therapy, LLC. I understand that I am responsible for all charges regardless of my insurance benefits and whether incurred by myself or a family member. I authorize the use of this signature on all insurance submissions. I may elect to pay any bill myself in lieu of submitting a claim for insurance reimbursement. I further agree that if Advanced Nutrition Therapy, LLC refers all or part of the unpaid portion of any bill to an attorney or agency for collection, I am liable for and shall pay Advanced Nutrition Therapy, LLC attorney fees and/or collection agency fees resulting from the referral
I verify by my signature below that I have read and understand the above information, and give my permission as stated above.