Insurance Information

If we are billing insurance, please bring your card(s) to your appointment. Not all insurance companies provide coverage for medication nutrition therapy or nutrition counseling. Please verify coverage with your provider. Note that patients are responsible for all non-covered charges, including co-pays, co-insurance, deductible, and/or non-covered services.

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Welcome, and thank you for choosing Northern Nutrition as your nutrition care team. We look forward to helping you achieve the goals which motivated you to reach out to us. The guidelines below have been established to facilitate our work together.

Confidentiality

Our sessions are held in strict confidence. A release form will be used to obtain permission to communicate with your referring physician or other healthcare professionals, as well as friends and/or family members if you choose—this is the Patient Authorization to Use/Disclose Health Information form.

Payment Policy

Payment is required at the time of your session, unless insurance is being billed or prior arrangements have been made. Cash, personal checks, and credit/debit cards are accepted (including flexible spending cards)—this office accepts Visa or Mastercard. If someone other than the client will be paying for the appointment, such as a parent paying for a child’s appointment, check or cash must be brought to the appointment, or a credit card number kept on file and charged at the appointment time.

Insurance Billing & Fee Schedule

Northern Nutrition is contractually obligated to bill any and all insurance companies with which we are contracted. Several insurance companies cover Medical Nutrition Therapy (MNT) or Nutrition Counseling as a benefit. You are advised to contact your insurance company if you are concerned about coverage—we bill using several CPT/procedure codes, most commonly either 97802 or 99404. You may have a deductible to meet before particular services are covered; your insurance plan may include a coinsurance or copay amount per visit; your plan may cover for only specific diagnoses; or your specific plan may not include coverage for our services. Any balances not covered by insurance are transferred to the patient’s responsibility. Charges that are pending insurance reimbursement greater than 60 days from the billed date are also transferred to the patient’s responsibility. If we receive insurance reimbursement thereafter, we will issue a refund check to the patient within 30 days of receipt of that insurance payment. If you believe your insurance plan should have paid for any denied or unpaid claims, you can appeal to your insurance company. We do reduce any amounts denied by insurance to our discount cash price.

Fee Schedule

Call for current self-pay/cash rates. We also offer discounted cash package pricing. For our Veterans and those with insurance for military members (i.e. TRICARE and TriWest) and family members on that insurance plan, we discount each and every visit an additional $50—we just ask that you show us your Veteran ID card or military insurance card. Our fee schedule also applies to scheduled telehealth (via phone or video) consultations.

Late Cancellations & No-Shows

24-hour notice is required for all cancellations—72 hours for Monday appointments, as our office is not open on Fridays; with such prior notice, we are able to schedule someone else in your time slot. Appointments cancelled without proper notice will be charged $50.00, not billable to insurance. We know that life happens, and if you cancel the day of your appointment due to unforeseen circumstances, you can reschedule that visit to avoid the late cancellation fee. Appointments missed altogether with no notice beforehand (also referred to as no-shows) will be charged $50.00, also not billable to insurance. After the first no-show, we reserve the right to no longer schedule you as our patient. Lastly, if you are more than 15 minutes late for your appointment, you will be asked to reschedule that visit so that we are able to stay on schedule for the remainder of our patients scheduled that day.

Correspondence Between Visits

We are available to assist you by phone for a few minutes if you need to speak with your provider between sessions—leave us a message with your phone number and we will return your call as soon as possible. We also respond to text messages and emails as we are able. If you need more than a few minutes on the phone or a text or email response requires more time, please consider scheduling an appointment to sit and meet with your dietitian. Unfortunately, we do not have the flexibility to spend more than a few minutes at a time outside of our scheduled visits.

Cell Phone Use

So that we may give you the time and attention you deserve, please turn off cell phones or put them on vibrate during our visit(s).

Your signature indicates that you have read, understand, and agree to the above policies. Please feel free to ask any questions; our goal is to meet your needs and provide you with optimal nutrition care.

Note:

If Medicare doesn't pay for the Services below, you may have to pay.
Medicare does not pay for everything, even some care that you or your health care provider have good reason to think you need. We expect that Medicare may not pay for the Services below:

Service:	Reason Medicare May Not Pay:	Estimated Cost:
Medical Nutrition Therapy	Medicare does not typically cover nutrition counseling for diagnoses other than diabetes or kidney disease.	$65-$72 per 15-minute session

What You Need To Do Now:

• Read this notice, so you can make an informed decision about your care.
• Ask us any questions that you may have after you finish reading.
• Choose an option below about whether to receive the Services listed above.

NOTE:  If you choose Option 1 or 2, we may help you to use any other insurance that you might have, but Medicare cannot require us to do this.

 

Please read the explanations carefully.

Option 1, Bill Medicare. I want the Services listed above. You may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn’t pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN. If Medicare does pay, you will refund any payments I made to you, less co-pays or deductibles.

Option 2, Self-Pay. I want the Services listed above, but do not bill Medicare. You may ask to be paid now as I am responsible for payment. I cannot appeal if Medicare is not billed.

Option 3, Decline Services. I don't want the Services listed above. I understand with this choice I am not responsible for payment, and I cannot appeal to see if Medicare would pay.

This notice gives our opinion, not an official Medicare decision. If you have other questions on this notice or Medicare billing, call 1-800-MEDICARE (1-800-633-4227/TTY: 1-877-486-2048).

Signing below means that you have received and understand this notice. You also receive a copy.

Note:

If your insurance carrier doesn’t pay for the Service(s) below, you may have to pay.

Your insurance carrier does not pay for everything, even some care that you or your healthcare provider have good reason to think you need. Your insurance carrier may not pay for the Service(s) below.

Service:	Reason Insurance May Not Cover:	Estimated Cost:
Medical Nutrition Therapy	Not all insurance plans have benefits to cover this service.	$65-$72 per 15-minute session

What You Need To Do Now:

• Read this notice, so you can make an informed decision about your care.
• Ask us any questions that you may have after you finish reading.
• Sign below if you would like to receive the Service(s) listed above. 

Signing below means that you have received and understand this notice. You will also receive a copy.

THIS NOTICE DESCRIBES HOW PROTECTED HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

If you have any questions about this notice, please contact: 

Northern Nutrition

1125 E Polston Ave, Suite A
Post Falls, ID 83854
Phone: (208) 640-4502
Fax:      (208) 777-7330
Email: admin@northernnutrition.net  

OUR PLEDGE REGARDING PROTECTED HEALTH INFORMATION

Northern Nutrition understands that protected health information about you and your health is personal. She is committed to protecting health information about you. This Notice applies to all records of your care generated by Northern Nutrition, whether made by Northern Nutrition personnel or your personal doctor.

This Notice will tell you about the ways in which office personnel may use or disclose protected health information about you. Rights and certain obligations are also described regarding the use and disclosure of protected health information.

Federal law requires the office to: 

• Make sure that protected health information that identifies you is kept private;  
• Notify you about how health information about you is protected;
• Explain how, when, and why protected health information is disclosed; and
• Follow the terms of the Notice that is currently in effect.

Northern Nutrition is required to follow the procedures in this Notice. The office reserves the right to change the terms of this Notice and to make new Notice provisions effective for all protected health information maintained by:

• Posting the revised Notice in the office;
• Making copies of the revised Notice available upon request; and
• Posting the revised Notice on the office website.

HOW OFFICE PERSONNEL MAY USE AND DISCLOSE PROTECTED HEALTH INFORMATION ABOUT YOU

The following categories describe different ways that office personnel may use and disclose protected health information without your written authorization.   

For Treatment. Office personnel may use protected health information about you to provide you with, coordinate, or manage your medical treatment or services. Office personnel may disclose protected health information about you to doctors, nurses, technicians, medical students, or other personnel within Northern Nutrition personnel, including persons outside of our office who are involved in your medical care. 

Northern Nutrition staff may also share protected health information about you in order to coordinate your care for such reasons as prescriptions, labwork, and imaging.  

The office may use and disclose protected health information to contact you as a reminder that you have an appointment for treatment or medical care at Northern Nutrition. The office may use and disclose protected health information to tell you about or recommend possible treatment options, treatment alternatives, or health-related benefits or services that may be of interest to you.  

For Payment for Services. The office may use and disclose protected health information about you so that the treatment and services you receive at Northern Nutrition may be billed to and payment may be collected from you, an insurance company, or a third party. For example, the office may need to give your health plan information about nutrition services you received at Northern Nutrition so your health plan will pay us or reimburse you for the service. The office may also tell your health plan about the nutrition services you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment. 

For Health Care Operations. The office may use and disclose protected health information about you for Northern Nutrition health care operations, such as our quality assessment and improvement activities, case management, coordination of care, business planning, customer service, and other activities. These uses and disclosures are necessary to run the facility, reduce health care costs, and make sure that all patients receive quality care.  

For example, the office may use protected health information to review our treatment and services or to evaluate the performance of the dietitian who is providing your services. The office may also combine protected health information about many Northern Nutrition patients to decide what additional services Northern Nutrition should offer, what services are not needed, and whether certain treatments are effective. The office may also disclose information to doctors, nurses, technicians, medical students, and other personnel at Northern Nutrition for review and learning purposes. Subject to applicable state law, the law allows or requires us to use or disclose your health information without your authorization in some limited situations for purposes beyond treatment, payment, and operations. 

As Required by Law. The office will disclose protected health information about you when required to do so by federal, state, or local law. 

Research. The office may disclose your protected health information to researchers when their research has been approved by an institutional review board or privacy board that has reviewed the research proposal and established protocols to ensure the privacy of your information. The office may permit researchers to review records to help identify patients who may be included in their research projects or for similar purposes as long as the researchers do not remove or take a copy of any health information.

To Avert a Serious Threat to Health or Safety. The office may use and disclose protected health information when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. 

The office may also disclose protected health information about you to a government authority if the office has reason to believe that you are a victim of abuse, neglect, or domestic violence. The office will only disclose this type of information to the extent required by law, and the office will only disclose it if (a) you agree to the disclosure, or (b) the disclosure is allowed by law and the office personnel believe it is necessary to prevent or lessen a serious and imminent threat to you or another person.

Judicial and Administrative Proceedings. The office may disclose your protected health information in response to a court or administrative order. The office may also disclose your protected health information in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made, either by us or the requesting party, to tell you about the request or to obtain an order protecting the information requested.  

Business Associates. The office may disclose information to business associates who perform services on our behalf (such as billing companies). However, the office requires that these associates appropriately safeguard your information. Our business associates are obligated to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.

Public Health.  As required by law, the office may disclose your protected health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.  

Health Oversight Activities. The office may disclose protected health information to a health oversight agency for activities authorized by law. These activities include audits, investigations, and inspections, as necessary for licensure and for the government to monitor the health care system, government programs, and compliance with civil rights laws.

Law Enforcement. The office may release protected health information as required by law, or in response to an order or warrant of a court, a subpoena, or an administrative request. The office may also disclose protected health information in response to a request related to identification or location of an individual, a victim of crime, a decedent, or a crime on the premises.  

Organ and Tissue Donation. If you are an organ donor, the office may release protected health information to an organ donation bank or to organizations that handle organ procurement or organ, eye, or tissue transplantation, as necessary to facilitate organ or tissue donation and transplantation.

Special Government Functions. If you are a member of the armed forces, the office may release protected health information about you if it relates to military and veterans activities. The office may also release your protected health information for national security and intelligence purposes, protective services for the President, and medical suitability or determinations made by the Department of State. 

Coroners, Medical Examiners, and Funeral Directors. The office may release protected health information to a coroner or medical examiner. This release may be necessary, for example, to identify a deceased person or determine the cause of death. The office may also disclose protected health information to funeral directors, consistent with applicable laws, to enable them to carry out their duties.

Correctional Institutions and Other Law Enforcement Custodial Situations. If you are an inmate of a correctional institution or under the custody of a law enforcement official, the office may release protected health information about you to the correctional institution or law enforcement official as necessary for your or another person’s health and safety.

Worker’s Compensation. The office may disclose protected health information as necessary to comply with laws relating to worker’s compensation or other similar programs established by law.

Food and Drug Administration (FDA). The office may disclose to the FDA, or persons under the jurisdiction of the FDA, protected health information relative to adverse events with respect to drugs, foods, supplements, products, and product defects, or postmarketing surveillance information to enable product recalls, repairs, or replacement.

Fundraising. The office may also contact you as part of fundraising efforts.  You have the right to opt out of receiving such communications.  

YOU CAN OBJECT TO CERTAIN USES AND DISCLOSURES

Unless you object, or request that only a limited amount or type of information be shared, the office may use or disclose protected health information about you in the following circumstances:

The office may share with a family member, relative, friend, or other person identified by you protected health information that is directly relevant to that person’s involvement in your care or payment for your care. The office may also share information to notify these individuals of your location, general condition, or death.
The office may share protected health information with a public or private agency (such as the American Red Cross) for disaster relief purposes. Even if you object, the office may still share this information if necessary under emergency circumstances.

If you would like to object to use and disclosure of protected health information in these circumstances, please call or write to the contact person listed on page 1 of this Notice.

YOUR RIGHTS REGARDING PROTECTED HEALTH INFORMATION ABOUT YOU

You have the following rights regarding protected health information that the office maintain about you:

Right to Inspect and Copy. You have the right to inspect and copy protected health information that may be used to make decisions about your care or payment for your care.  If the office maintains your protected health information electronically, you can request that the office provide access in an electronic form and format that is readily producible, or in a form and format agreed to by us.    

To inspect and copy protected health information that may be used to make decisions about you, you must submit your request in writing to Northern Nutrition. If you request a copy of the information, the office may charge a fee for the costs of copying, mailing, or supplies associated with your request. The office may not charge you a fee if you need the information for a claim for benefits under the Social Security Act or any other state or federal needs-based benefit program. The office will respond to your request no later than 30 days after the office receive it. There are certain situations in which the office is not required to comply with your request. In these circumstances, the office will respond to you in writing, stating why the office will not grant your request and describe any rights you may have to request a review of our denial.

Right to Amend. If you feel that protected health information the office has about you is incorrect or incomplete, you may ask us to amend or supplement the information. 

To request an amendment, your request must be made in writing and submitted to Northern Nutrition. In addition, you must provide a reason that supports your request. The office will act on your request for an amendment no later than 60 days after the office receives it.

The office may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In these circumstances, the office will provide a written denial stating why the office will not grant your request. In addition, the office may deny your request if you ask us to amend information that:

- Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
- Is not part of the protected health information kept by Northern Nutrition;
- Is not part of the information that you would be permitted to inspect and copy; or 
- The office believes is accurate and complete.

Right to an Accounting of Disclosures. You have the right to request an “accounting of disclosures.” This is a list of the disclosures the office made of protected health information about you.  

To request this list of disclosures, you must submit your request in writing to Northern Nutrition. You may ask for disclosures made within the six (6) years before your request. The first list you request within a 12-month period will be free. For additional lists in that 12-month period, the office may charge you for the costs of providing the list. The office is required to provide a list of all disclosures except the following:

• Disclosures made for your treatment;
• Those used for billing and collection of payment for your treatment;
• Those related to health care operations;
• Those made to you or requested by you, or those that you authorized;
• Those that occurred as a byproduct of permitted use and disclosures;
• Those used for national security or intelligence purposes, or provided to correctional institutions or law enforcement regarding inmates;
• Those that were a part of a limited data set of information that does not contain information identifying you.

Right to Request Restrictions. You have the right to request a restriction or limitation on the protected health information the office uses or discloses about you for treatment, payment, or health care operations, or to persons involved in your care.  

The office is not required to agree to your request. If the office does agree, the office will comply with your request unless the information is needed to provide you emergency treatment, the disclosure is to the Secretary of the Department of Health and Human Services, or the disclosure is required by law.  

To request restrictions, you must make your request in writing to Northern Nutrition.

Right to Request Confidential Communications. You have the right to request that the office communicate with you about medical matters in a certain way or at a certain location.  For example, you can ask that the office only contact you at work or by mail.  

To request confidential communications, you must make your request in writing to Northern Nutrition. The office will accommodate all reasonable requests.   

Right to a Paper Copy of This Notice. You have the right to a paper copy of this Notice at any time. To receive a paper copy, contact Northern Nutrition.

Right to Receive Notice of Breach. You have a right to be notified upon a breach of any of your unsecured protected health information.

Rights for Out-of-Pocket Payments. If you paid out of pocket in full for a specific item or service, you have a right to ask that your protected health information with respect to that item or service not be disclosed to a health plan for purposes of payment or health care operations.  The office is required to agree to your request unless the disclosure is otherwise required by law.  

TYPES OF USES AND DISCLOSURES REQUIRING AN AUTHORIZATION

Most uses and disclosures of psychotherapy notes require us to obtain an authorization from you.  In addition, in most instances, the office cannot use or disclose your protected health information for marketing purposes or sell your protected health information without your written authorization.  Finally, any other use or disclosure not described in this Notice will be made only with your authorization.  Any time you provide the office with a written authorization, you may revoke it any time in writing, to the extent that the office has not already taken action in reliance on your previous authorization.

OTHER USES AND DISCLOSURES

The office will obtain your written authorization before using or disclosing your protected health information for purposes other than those described in this Notice (or as otherwise permitted or required by law). You may revoke this authorization in writing at any time. Upon receipt of the written revocation, the office will stop using or disclosing your information, except to the extent that the office has already taken action in reliance on the authorization. 

YOU MAY FILE A COMPLAINT ABOUT OUR PRIVACY PRACTICES

If you believe your privacy rights have been violated, you may file a complaint with Northern Nutrition or file a written complaint with the Secretary of the Department of Health and Human Services. A complaint to the Secretary should be filed within 180 days of the occurrence or action that is the subject of the complaint.

If you file a complaint, the office will not take any action against you or change our treatment of you in any way.

CHANGES TO THIS NOTICE 

The office reserves the right to change this Notice and make the new Notice apply to health information the office already has, as well as any information the office receives in the future. The office will post a copy of our current Notice in our office. The notice will have the effective date clearly marked at the top of the first page.

Under HIPAA privacy regulations, covered entities must: distribute a Privacy Notice to all patients and clients upon first service delivery and obtain a written acknowledgment of receipt.

 

Acknowledgement - Receipt of Notice of Privacy Practices

By signing this document and providing my name below, I am acknowledging that I have received a copy of the HIPAA Privacy Practices Notice for the office of Northern Nutrition.