Nourish Info, Consent, HIPPA and Release Agreement
Welcome to Nourish — we are excited to meet you! Please take a few moments to read our practice policies. This agreement is between you and Nourish.
The intake appointment is usually 60 minutes. Follow up appointments are normally 60 minutes. If you are late for a session, you may lose some of that session time.
CANCELING AND RESCHEDULING APPOINTMENTS:
I understand that if I need to cancel or reschedule my appointment, Nourish requires at least 24 hours prior notice. If I do not provide Nourish with 24 hours notice, I will be charged a $145 No Show/Late Cancel Fee. This charge will be made to the credit card on file. This fee is not covered by your insurance and your insurance copay does not apply. By signing this form, I understand the Nourish policy and agree that Nourish may charge my credit card on file for these fees, usually on the day they occur.
Using the phone number and email that I provide in Nourish's intake process, Nourish may contact me via email and text messages for client care communication and occasional marketing purposes. Nourish cannot ensure 100 percent confidentiality of communication through electronic media, including text/email messages and emails. I understand that texting, calling and emailing are not a secure or confidential form of communication. I recognize that I may opt out to these communications at any time by contacting firstname.lastname@example.org
Via your electronic signature (by clicking the checkbox as applicable), you voluntarily consent to sign electronically (“E-Sign”) documents presented to you (including those for signature) relating to Nourish, Inc. You agree that Nourish may accept an electronic signature from you and will have the same effect as a physical “wet” signature. At any time, you may withdraw your consent.
In order to provide a high level of care, it is company policy that sessions cannot be conducted if a client is in a public setting without headphones or adequate privacy, driving a car (if the car is parked or they are a passenger for the entirety of the session that is okay), highly distracted or multi-tasking to the point that it is interfering with the dietitian’s ability to conduct the session, or engaging in any behavior that is not respectful or appropriate toward the registered dietitian.
Parents may be legally entitled to some information about sessions. We will discuss with the minor and parents what information is appropriate for them to receive and which issues are more appropriately kept confidential.
YOUNG ADULTS Ages 18-26:
If you are currently on your parent’s health insurance, and/or they are providing financial assistance to pay for our services, we will ask you to sign a Release of Information allowing us to speak with your parent(s), limited to ONLY financial and insurance reasons.
PROTECTED HEALTH INFORMATION (Health Insurance Portability and Accountability Act - HIPAA)
This notice describes how health information may be used and disclosed and how you can get access to this information.
Nourish (“We”) is committed to protecting your health information. Your provider will create a file of the care and services you receive, which helps provide you with quality care and allows us to comply with certain legal requirements.
We are required by law to:
• Make sure that protected health information (“PHI”) that identifies you is kept private.
• Give you this notice of our legal duties and privacy practices with respect to health information.
• Follow the terms of the notice that is currently in effect.
• We can change the terms of this notice, and such changes will apply to all information we have about you. The new notice will be available upon request in our office or via email.
1. How we may use and disclose health information about you:
FOR TREATMENT PAYMENT OR HEALTH CARE OPERATIONS: Federal privacy rules allow health care providers who have direct treatment relationship with the patient/client to use or disclose the patient/client’s personal health information without the patient’s written authorization, to carry out the health care provider’s own treatment, payment or health care operations. We may also disclose your protected health information for the treatment activities of any health care provider. This can be done without your written authorization. For example, if a clinician were to consult with another licensed health care provider about your condition, we would be permitted to use and disclose your person health information, which is otherwise confidential, in order to assist the clinician in diagnosis and treatment of your health condition. Disclosures for treatment purposes are not limited to the minimum necessary standard. Health care providers need access to the full record and/or full and complete information in order to provide quality care. The word “treatment” includes, among other things, the coordination and management of health care providers with a third party, consultations between health care providers and referrals of a patient for health care from one health care provider to another.
LAWSUITS AND DISPUTES: If you are involved in a lawsuit, we may disclose health information in response to a court or administrative order. We may also disclose health information about your child 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 to tell you about the request or to obtain an order protecting the information requested.
2. Certain uses and disclosures require your authorization:
1. Nutrition Notes. We do keep “nutrition notes” as that term is defined in 45 CFR § 164.501, and any use or disclosure of such notes requires your authorization unless the use or disclosure is: A) For my use in treating you. B) For use in training or supervising other practitioners to help them improve their skills. C) For my use in defending myself in legal proceedings instituted by you. D) For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA. E) Required by law and the use or disclosure is limited to the requirements of such law. F) Required by law for health oversight activities pertaining to the originator of the nutrition notes. G) Required to help avert a serious threat to the health and safety of others.
2. Marketing Purposes. We will not use or disclose your PHI for marketing purposes.
3. Sale of PHI. We will not sell your PHI in the regular course of our business.
3. Certain uses and disclosures do not require your authorization:
Subject to certain limitations in the law, I can use and disclose your PHI without your authorization for the following reasons:
1. When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.
2. For public health activities, including reporting suspected abuse, or preventing or reducing a serious threat to anyone’s health or safety.
3. For health oversight activities, including audits and investigations.
4. For judicial and administrative proceedings, including responding to a court or administrative order.
5. For law enforcement purposes, including reporting crimes occurring on my premises.
6. To coroners or medical examiners, when such individuals are performing duties authorized by law.
7. For research purposes, including studying and comparing the health of patients who received one form of therapy versus those who received another form of therapy for the same condition.
8. Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counter-intelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions.
9. We may provide your PHI in order to comply with workers’ compensation laws.
10. We may use and disclose your PHI to contact you to remind you that you have an appointment with us.
4. Certain uses and disclosures require you to have the opportunity to object:
1. We may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.
5. You have the following rights with respect to your PHI:
A. The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask us not to use or disclose certain PHI for treatment, payment, or health care operations purposes. We are not required to agree to your request, and we may say “no” if we believe it would affect your health care.
B. You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full.
C. You have the right to ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and we will agree to all reasonable requests.
D. Other than “nutrition notes,” you have the right to an electronic or paper copy of your medical record and other information that we have about you. We will provide you with a copy of your record, or a summary of it, within 30 days of receiving your written request and we may charge a reasonable cost for doing so.
E. You have the right to request a list of instances in which we have disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided us with an authorization. We will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list we will give you will include disclosures made in the last six years unless you request a shorter time. We will provide the list to you at no charge, but if you make more than one request in the same year, we may charge you a reasonable cost for each additional request.
F. If you believe that there is a mistake in your PHI, or that a piece of important information is missing from your PHI, you have the right to request that we correct the existing information or add the missing information. we may say “no” to your request, but we will tell you why in writing within 60 days of receiving your request.
G. You have the right get a paper copy of this notice, and you have the right to get a copy of this notice by e-mail.
This notice went into effect on September 20, 2013
Acknowledgement of Receipt of Privacy Notice. Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. By signing below, you are acknowledging that you have received a copy of this HIPPA Notice of Privacy Practices.
CONSENT TO TREAT, WAIVER AND RELEASE
1. CONSENT TO MEDICAL CARE: By my signature, I warrant that I am the patient, parent or legal guardian of the child(ren) named. I hereby request and authorize the dietitians and other health care providers of Nourish and their professional staff, to perform any medical care which in their professional judgment is deemed necessary to treat the conditions(s) that have brought about my seeking medical care services for myself or my child(ren) at the offices of Nourish. I understand that the practice of medicine is not an exact science, and that there are risks and benefits associated with receiving medical treatment. I acknowledge and agree that no guarantees are made to me concerning the results and outcomes of the medical examination and treatment rendered by the dietitians and professional staff of Nourish.
2. RELEASE AND WAIVER: The Registered and Licensed Dietitians of Nourish do not diagnose or treat disease. You should consult a physician for diagnosis before undergoing any dietary or food supplement changes. Any recommendations you follow for changes in diet, including but not limited to the use of food supplements, are entirely your responsibility. In consideration of my participation in nutrition counseling, I hereby accept all risk to my health and of any injury or death that may result from participation. I hereby release Nourish from any liability to me, my personal representatives, estate, heirs, next of kin and assign for any and all claims and causes of action for loss of or damage to my property and for any and all illness or injury to my person, including my death, that may result from or occur during my participation in nutrition counseling, whether caused by negligence of Nourish or otherwise. I further agree to indemnify and hold harmless Nourish from liability for the injury or death of any person(s) and damage to property that may result from my negligent or intentional act or omission while participating in the described nutrition counseling session. I further understand that all of the communications from Nourish including but not limited to handouts, nutrition counseling and website content offer no guaranteed cure for disease.
3. RELEASE OF MEDICAL RECORD INFORMATION. I hereby authorize Nourish to disclose any or all of the contents of the medical record of the patient named on this form to such insurance companies, organizations, or agencies that may be concerned with the payment of medical services rendered to the registered patient(s) consistent with Federal HIPAA regulations. This authorization is given with full knowledge and understanding that such disclosure may contain information which may result in a valid denial of insurance benefits, or which otherwise may not serve the interests of the registered patient(s) or myself.
4. ASSIGNMENT OF INSURANCE BENEFITS: I hereby request and authorize that any and all insurance benefits due and payable for medical services rendered to the patients(s) be paid directly to Nourish.
5. CORRECT INFORMATION: The undersigned certifies that he/she has provided correct information in this form. The undersigned further certifies that he/she has read, fully understands, and accepts the above information, terms and conditions, and is the patient’s parent or legal guardian, duly authorized to execute the above and to accept its terms.
6. CHILDREN UNDER 18 MUST HAVE A PARENT OR GUARDIAN PRESENT: Children under the age of 18 cannot legally consent to their own treatment. Treatment can only be approved by a parent or legal guardian. If you cannot attend their appointment and must send your child(ren) alone, or with an older sibling, grandparent, or nanny, please be aware that they have no legal authority to provide a “consent to treatment” for your child. You must send a SIGNED LETTER OF AUTHORIZATION WITH THEM, or give us written authorization naming the person(s) you approve in advance to consent to treatment on your behalf. If you wish to do this, please request an AUTHORIZATION FORM from our staff.
7. CONSENT FOR TELEHEALTH CONSULTATION
I understand that my health care provider wishes me to engage in a telehealth consultation.
My health care provider explained to me how the video conferencing technology that will be used to affect such a consultation will not be the same as a direct client/health care provider visit due to the fact that I will not be in the same room as my provider.
I understand that a telehealth consultation has potential benefits including easier access to care and the convenience of meeting from a location of my choosing.
I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my health care provider or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.
I have had a direct conversation with my provider, during which I had the opportunity to ask questions in regard to this procedure. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand.
8. CONSENT TO USE ZOOM FOR TELEHEALTH
Zoom is the technology service we will use to conduct telehealth videoconferencing appointments. It is simple to use and there are no passwords required to log in. By signing this document, I acknowledge:
Zoom is NOT an Emergency Service and in the event of an emergency, I will use a phone to call 911.
Zoom facilitates videoconferencing and is not responsible for the delivery of any healthcare, medical advice or care.
I do not assume that my provider has access to any or all of the technical information in Zoom – or that such information is current, accurate or up-to-date. I will not rely on my health care provider to have any of this information in Zoom.
To maintain confidentiality, I will not share my telehealth appointment link with anyone unauthorized to attend the appointment.
By consenting to this form, I certify:
That I have read or had this form read and/or had this form explained to me.
That I fully understand its contents including the risks and benefits of the procedure(s).
That I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.
BY ADVANCING IN NOURISH'S INTAKE FLOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO ALL THE ITEMS CONTAINED IN THIS DOCUMENT.