PLEASE REMEMBER that insurance is considered a method of reimbursing the patient for fees paid to the medical provider and is not a substitute for payment. My agreement with the insurance company is between my insurance company and I.

I understand it is my responsibility:

• For knowing the terms, regulations, and limitations of my insurance plan.
• For obtaining referrals when they are required by my insurance plan for coverage.
• To pay any deductible, co-insurance or non-covered amount not paid by my insurance plan for care provided to me or my dependent.

Washington Nutrition Group makes no guarantee of insurance coverage or insurance payments. If the patient’s insurance company does not pay for the service(s) 60 days after the claim is submitted the patient will be sent a bill. If payment is not received within 30 days after the bill is sent out, my credit card on file will be charged and a receipt will be mailed. If the amount is not collected by mail payment or credit card a pre-collection letter will be sent and after 30 days collection procedures are required for unpaid balances. I am responsible for all costs of collections including, but not limited to, collections fees (generally 30-50%), interest at eighteen percent (18%) from the last date of payment, and any court costs.

If Washington Nutrition Group later receives payment from my insurance company, I will be reimbursed for any overpayments (less co-payments, co-insurance, or other allowable charges).

Returned Checks: I will pay a $35 fee for a returned check in addition to my full balance, with cash or credit card, within 10 days of being notified by Washington Nutrition Group.

Missed or Cancellation of an Appointment: Missed appointments not canceled or rescheduled 24 BUSINESS HOURS ahead of time will be charged $80 for an initial appointment and $40 for a follow up appointment. BUSINESS HOURS are considered Monday to Friday from 9am to 4pm. e.g. If your appointment is scheduled on a Monday, the cancellation must be done on Friday during bussiness hours. 

This notice covers all information in our written and electronic records about your health. Washington Nutrition Group dietitian-nutritionists, personal trainers and staff may use and disclose medical information (Protected Health Information -- PHI) about an individual for medical treatment, payment and health care operations.

Washington Nutrition Group is permitted, or required under specific circumstances, to use or disclose protected health information without the individual’s written authorization, including but not limited to: disclosures required by law, disclosures to avert serious threats to health or safety, disclosures with reference to workers compensation, or disclosures to public health authorities (as examples, but not limited to the Food and Drug Administration (FDA), the Centers for Disease Control and Prevention, and the Occupational Safety and Health Administration (OSHA)).

Other uses and disclosures will be made only with the individual’s written authorization and the individual may revoke such authorization. (To provide a written authorization of this protected information, please see next page).

Washington Nutrition Group’s office policy is to contact the individual by phone, SMS, or email to provide appointment reminders; or information about treatment or other health-related benefits and services that may be of interest to the individual or patient.

Washington Nutrition Group will routinely contact patients by telephone, SMS, or email at home and/or at work; and,
otherwise unless requested, may leave messages on the appropriate answering or messaging service regarding appointments, test results, etc.

Our patients have the following rights regarding their protected health information (PHI):

• A. The right to request restrictions on certain uses and disclosures of protected health information; however, Washington Nutrition Group is not required to agree to a requested restriction.
• B. The right to receive confidential communications of protected health communication.
• C. The right to inspect and copy protected health information.
• D. The right to amend protected health information.
• E. The right to receive an accounting of disclosures of protected health information.
• F. The right to obtain a paper or electronic copy of this Notice.

Washington Nutrition Group is required by law to maintain the privacy of protected health information and to provide individuals with notice of its legal duties and privacy practices with respect to protected health information. 

Washington Nutrition Group is required to abide by the terms of the Notice currently in effect.

Washington Nutrition Group reserves the right to change the terms of this Notice. The new Notice provisions will be effective for all protected health information that it maintains. Washington Nutrition Group will provide individuals with a revised Notice per request.

Authorizations:

Please provide the name(s) of person(s), if any, to whom you permit Washington Nutrition Group to disclose personal health information, as necessary, for your continued health care. Please also note if specific health care information cannot be disclosed (i.e. test results, appointment information, etc). Otherwise, we will disclose only what is necessary for your continued health care in accordance to this privacy policy.

Name and relationship of person(s) permitted to received PHI

List below providers you DO NOT want all or specific health information sent:

DO NOT SEND PHI to the following providers

I acknowledge and understand Washington Nutrition Group policy is to contact me by varios means when necessary for my health care services that may include my home/work/cell phones, fax, SMS, or email. I also understand that private health information may be included in that communication to me.

I hereby acknowledge that I have read the Washington Nutrition Group Notice of Privacy Practices and received a copy (if requested).

Nutrition and/or Fitness Disclaimer

The nutrition advice given by “Washington Nutrition Group” is solely based on the information provided by the client/individual. The nutrition information given is meant only for the client / individual completing the nutrition questionnaire form. It is the sole responsibility of the client / individual to provide complete and provide accurate information. Any misinformation, inaccurate or omitted information may affect the nutritional assessment and/or advice. Any misrepresented information is solely the client’s / individual’s responsibility. “Washington Nutrition Group” will not be liable.

“Washington Nutrition Group” provides nutrition counseling only and is not licensed to prevent, diagnose, alleviate or treat any medical conditions, disease, physical or mental ailments or pain or infirmities.

Nutrition and/or Fitness Waiver and Covenant Not to Sue

I have volunteered to participate in a nutrition program under the direction of “Washington Nutrition Group” which will include, but may not be limited to nutrition planning. In consideration of “Washington Nutrition Group” agreement to assist me, I do here and forever release and discharge and hereby hold harmless “Washington Nutrition Group”, and their respective agents, heirs, assigns, contractors, and employees from any and all claims, demands, damages, rights of action or causes of action, present or future, arising out of or connected with my participation in any nutrition program including any injuries resulting there from. I acknowledge and agree that no warranties or representations have been made to me regarding the results I will achieve from this program. I understand that results are individual and may vary.

Nutrition Assumption of Risk
I recognize that specific foods may create allergic and possible fatal reactions, most specifically, products containing nuts. I have therefore specified any food allergies/ sensitivities I am aware of. I am aware that specific foods may interact with certain medications. I have discussed such food reactions and the side effects of all of my medications with my doctor or pharmacist and do not hold “Washington Nutrition Group” responsible for food and medication reactions. I also understand the diet plan I receive will not take my medications into consideration. If I am on medications, I am responsible to consult with my doctor before starting a new diet plan. If I am pregnant or lactating, have high cholesterol, high blood pressure, high blood sugar, diabetes, renal disease, gastric by-pass surgery a family history of gout or any other medical condition that requires special dietary restrictions, I must receive permission from my physician before participating in the specific nutrition program designed for my use, or may be advised to seek help from another health  professional.

We require your credit card authorization to be on file before we can process your request for service. For your convenience, we will use this authorization to charge your credit card account for any additional amounts incurred as a result of surcharges and/or services not covered by your insurance. We will contact you before charging your credit card.  

No credit card information is ever stored on our servers.  We use Stripe.com, one of the most secure and reputable payment processors available. All card numbers are encrypted on disk with AES-256. Decryption keys are stored on separate machines. None of Stripe’s internal servers and daemons are able to obtain plaintext card numbers; instead, they can just request that cards be sent to a service provider on a static whitelist. Stripe’s infrastructure for storing, decrypting, and transmitting card numbers runs in separate hosting infrastructure, and doesn’t share any credentials with Stripe’s primary services (API, website, etc.).