Thank you for choosing Capital Area Medical Nutrition Associates (CAMNA). This form helps us prepare for your visit. Please complete it at least 48 hours before your appointment to avoid cancellation. Your information is kept private and secure (HIPAA-compliant). If you have issues submitting your form, please email us at info@camnamedus.com

Please read and acknowledge the following:

• My appointment may be canceled if this form is not submitted at least 48 hours in advance.
• My copay or self-pay amount is due prior to the session.
• I authorize Capital Area Medical Nutrition Associates to contact me via phone, text, or email for appointment-related communication.
• I will review and accept the Privacy Policy, Standard Office Policy Agreement and Credit Card Authorization Agreement listed at the end of this form.
  
  

Privacy Policy

Capital Area Medical Nutrition Associates (CAMNA) requires your consent to use and disclose your Protected Health Information (PHI) for purposes related to treatment, payment, and healthcare operations in accordance with federal privacy regulations (HIPAA).

You have the right to review our Notice of Privacy Practices before signing this consent. This document explains in more detail how your health information may be used and disclosed, and how you can access it.

The terms of our Notice of Privacy Practices may change from time to time. The most current version is always available upon request or can be obtained by contacting our office at 202-280-7523. A copy is also posted in our office.

You may revoke your consent at any time in writing. Please note that revocation will not apply to any actions CAMNA has already taken based on your original consent.

I acknowledge that I have had the opportunity to discuss the nature and purpose of medical nutrition therapy with the Registered Dietitian and/or office personnel. I understand that outcomes are not guaranteed.

I authorize CAMNA to send a summary of my consultation to my primary care physician or referring provider if needed.

By providing my phone number, I consent to receive communications from CAMNA regarding my appointments, billing, or treatment. This may include phone calls, voicemails, or text messages (SMS) using the number I’ve provided.

I understand that text messaging may not be a fully secure method of communication, and I accept the associated risks. I may opt out of non-essential text messages at any time by notifying CAMNA in writing.

By signing below, I give consent for CAMNA to use and disclose my protected health information as outlined above, and acknowledge that I may request a copy of this consent at any time.

Standard Office Policy Agreement

Thank you for choosing Capital Area Medical Nutrition Associates (CAMNA) as your nutrition specialist. The following rules will help facilitate a positive working relationship.

1. I hereby authorize CAMNA to apply for benefits on my behalf for covered services rendered. I certify that all information given is correct, and authorize the release of all information, including medical information, for this or related claims.

2. I understand CAMNA may bill me for services rendered upon denial of my insurance company/ Medicare-despite prior approval. I agree to be fully and personally responsible for payment.

3. All clients need to handle any bills in a timely fashion. Your Dietitian will not see you if you have an outstanding balance.

4. We allow 45 days for your insurance company to make payment to us. Sometimes insurance companies request more information before they make a payment; please respond promptly to your insurance company or CAMNA with requests for further information. If you fail to respond, you will be billed and expected to pay promptly.

5. Every insurance provider has different guidelines as to what diagnoses are covered. We strive to stay current with all insurance coverage guidelines, but we cannot guarantee any coverage.

6. It is your responsibility to obtain the proper referral and benefits approval prior to your visit and bring it with you. If a referral is faxed, please call to verify that it was received. Please do not ask us to get your referral.

If your insurance requires you to have a referral, you will not be seen by a dietitian without one unless you choose to self-pay the fee for the entire visit ($300 for initial visit, $200 for follow-up appointment) upfront. We will not submit this date of service to insurance; therefore, no refund will be given.

Co-pays are due at the beginning of the appointment. We do not bill for co-pays. We require a 24-hour notice to cancel/and/or change appointments or a $30.00 administrative fee will be applied if you fail to cancel your appointment or if you are a no show.

Please note that there is a $25 administrative fee for all records requested after an initial copy has been provided to you and a $5 fee associated with request for yearly receipts. There is a $25 fee for any returned checks. All payments for a returned check and further payments will be due in cash or money order only. If you do not remit payment within the designated time on your invoice your payment will be deemed as late and your account will be assessed a $25 late fee on your next statement. If your account is 90 days past due, it will be sent to a collection agency. A $25 collections fee will be issued.

I have read, understand, received a copy (if requested) and agree to these policies.

Credit Card Authorization Agreement

The purpose of this agreement is to authorize Capital Area Medical Nutrition Associates (CAMNA) to retain a valid credit card number on file for you as our patient. All new patients are required to complete this form. This form will be kept confidential and only authorized staff will have access to the information.

Your supplied credit card will be charged ONLY under the following circumstances:

1. CAMNA reserves the right to charge the credit card listed below for all current patient balances, including co-pays (following insurance payments) and a receipt will be kept in your patient chart, unless directed to send the receipt directly to you. This notice serves as your consent to being charged for all current patient balances on your account.

2. If you, as the patient, miss a scheduled appointment without 24-hour notice to cancel or reschedule, CAMNA reserves the right to charge the credit card listed below $30.00 for our standard no-show fee and a receipt will be sent to the current address or email address on file. This notice serves as your consent to being charged for any and all no-shows. As is customary, a text message and or email from CAMNA will be sent to you to remind you of your scheduled appointment. This reminder is usually done 1 week ahead of and 24 hours prior to your scheduled appointment. It is the patient’s responsibility to ensure we have a correct email and current telephone number on file.

3. If we receive notice that a payment is returned to us for any reason, CAMNA reserves the right to charge the credit card listed below a $25 returned check fee as well as a $25 processing fee. A receipt will be sent to

the current address or email address on file. This notice serves as your consent to being charged for any returned payments.

4. If you, as the patient, request a copy of your medical records we will provide to you an electronic copy free of charge, upon written request, a paper copy of your medical record will be provided. CAMNA reserves the right to charge our base fee of $25 to provide you with any additional copies of your record. This notice serves as your consent to being charged for medical records request.

Other than the conditions mentioned above, under NO circumstance will CAMNA charge your credit card for anything not discussed personally with you. In conjunction with HIPAA regulations, all credit card information will be confidentially kept within your medical chart in our EHR system. Only authorized staff will be able to access this information.

Having read this form and talked with the physician, practitioner and/or staff, my signature below acknowledges that I voluntarily give my authorization and consent to providing the requested information for my credit card to be charged accordingly for the conditions listed above.

 

Refusal to Complete Authorization:
Refusal to complete and agree to this authorization dictates the following: Since there is no credit card on file with CAMNA, CAMNA reserves the right to send only ONE statement to the address on file to notify you of your balance with our practice. Please note, there may be a discretionary charge of $20.00 for this statement. It is your responsibility to send the amount due within 15 days of your statement to avoid being sent to collections and having your account closed with our practice.