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I acknowledge the financial policy set forth below and agree to pay for services rendered to me by Fay Nutrition, LLC and affiliated entities (collectively, the “Practice”): Payment Information: It is our policy to require all clients to provide credit card and, if applicable, insurance information, at the time of booking. We will keep this information on file. It is your responsibility to notify Practice of changes to your card and insurance information. Charges that are not completed due to invalid or outdated information will remain your responsibility. Card Payment: We accept all major credit and debit cards, in addition to HSA and FSA cards. Your card information will be held securely. Insurance Policy: We try our best to verify eligibility and estimate pricing, but it is ultimately your responsibility to check coverage and out-of-pocket costs for services. If your insurance requires you to have a preauthorization or referral, you must obtain and provide these prior to your appointment, and we cannot guarantee your insurance plan will cover the cost of your appointment. For in-network visits, you are responsible for the patient responsibility amount as determined by your plan. While prior to the visit we cannot guarantee which CPT code or diagnosis code will be used, please feel free to ask your carrier about coverage and cost of your visit. If your claim is denied, missing, or delayed, you are responsible for the outstanding balance due, which is your provider’s full self-pay rate. For out-of-network visits, you will be billed at the provider’s self-pay rate, and we can provide an invoice for you to submit to your insurance for reimbursement. We cannot resubmit claims.
Payment Collection: Payment is due after each session, and Practice will charge your card or bank account for the patient responsibility or total outstanding balance due. Receipts may be provided at the time of the charge or monthly.
Cancellation and Missed Appointments: Appointments that are not cancelled 24 business hours in advance, and appointments that you are late by 50% of the allotted time, will be billed at up to your provider’s full self-pay rate. Unfortunately, bills for cancellations cannot be submitted to insurance for reimbursement. If you miss or “late” cancel two consecutive sessions, your provider may discharge you from their service. Residence: You confirm that you are a resident of the state in which you have selected during your experience of searching for your provider. You may file a complaint by filling out the privacy complaint submission form here.
I hereby authorize Practice to release information for the purposes outlined in this privacy policy statement and release Practice from any liability which may arise as a result of the use of the information contained in the copy of records released. I also authorize Practice to obtain my protected health information from other providers and/or services, including my medication history.
We may use and disclose your health information for the purposes of providing services and quality care. For the avoidance of doubt, providing treatment services, collecting payment and conducting healthcare operations are all necessary activities for quality care. State and federal laws allow us to use and disclose your health information for these purposes.For uses and disclosures for purposes other than treatment, payment and operations, we are required to have your written authorization, unless the use or disclosure falls within an exception, such as those described below. Most uses and disclosures of medical nutrition therapy notes (as that term is defined in the HIPAA Privacy Rule), uses and disclosures for marketing purposes, and disclosures that constitute the sale of Personal Information require your authorization. Authorizations can be revoked at any time to stop future uses/disclosures except to the extent that we may have already taken any action in reliance on your authorization. Disclosures can be made without an authorization in the following circumstances: emergencies, judicial and administrative proceedings, child/elder abuse, criminal activity or danger to others, health oversight reviews, business associate functions, research, general marketing, and scheduling appointments. Individual Rights are stated below.
Right to Inspect and Copy. You have the right to look at or get copies of your health information, with limited exceptions. Your request must be in writing. If you request a copy of the information, a reasonable charge may be made for the costs incurred.
Right to Amend. You have the right to request that we amend your health information. Your request must be in writing, and it must explain why the information should be amended. We have the right to deny your request under certain circumstances.
Right to an Accounting of Disclosures. You have the right to receive a list of instances in which we have disclosed your health information for a purpose other than treatment, payment, or health care operations. To request an accounting of disclosures, you must submit your request in writing to the Privacy Officer. Such accountings remain available for six years after the last date of service at the Practice.
Right to Request Restrictions. You have the right to request a restriction or limitation on the health information we use or disclose about you. For example, you could ask that we not share information with an insurance company, in which case you would be responsible to pay in full for the services provided. While you are in treatment, a written request should be made with your provider. To request a restriction after therapy is completed, you must make your written request to the Privacy Officer. We are not required to agree to your request, but we will consider the request very seriously.
Right to Request Confidential Communications. You have the right to request that we communicate with you about health matters in a certain way or at a certain location. For example, you may ask that we contact you only by mail or at work. You must make this request in writing and it must specify the alternative means or location that you would like us to use to provide you information about your health care. We will make every attempt to accommodate reasonable requests.
Right to File Complaints. You may complain to us and to the Secretary of Health and Human Services if you believe your privacy rights have been violated. You may file a complaint by filling out the privacy complaint submission form here.
Email and Text Messaging Use. As a client of Practice we may communicate with you over email or text message. Associates of Practice may communicate over email or text message as well. This is to promote convenience, but for urgent or an emergency situation, you should not rely on email or test message communication with providers affiliated with the Practice. In those situations, you should call 911. Email messages on your computer, laptop, or other device have inherent privacy and security risks, and you should be aware of those before seeing a provider affiliated with the Practice. In order to forward or to process and respond to your email or text message, individuals at the Practice and its business associates other than your health care provider may read your email or text message. Your email or text message is not a private communication between you and your treating provider. At your health care provider’s discretion, your email or text message any and all responses may become part of your medical record.
I hereby authorize Practice to use Telemedicine in the course of my diagnosis and treatment.
Nature of Telemedicine: Telemedicine provides nutrition counseling and/or medical nutrition therapy services using interactive audio, video and/or text conferencing tools in which the practitioner and the client are not at the same location. Telemedicine will allow the client to receive care without the need to visit the office.
Medical Records: All existing laws regarding access to medical information and disseminating medical records apply to care via Telemedicine.
Provider Choice of Care: The use of Telemedicine is determined by Practice.
Rights: You have the right to withhold or withdraw consent to the use of Telemedicine at any time during the course of care in writing. Alternatives to Telemedicine include traditional face-to-face sessions and Practice cannot guarantee availability of face-to-face sessions.
Confidentiality: Reasonable and appropriate efforts have been made to eliminate any confidentiality risks associated with Telemedicine. All confidentiality protections that exist under federal law apply to information disclosed during Telemedicine sessions.
Potential Risks: Potential risks include, but may not be limited to: information transmitted may not be sufficient (poor resolution of audio and/or video): delays in medical evaluation and treatment due to deficiencies or failure of the equipment; security protocols can fail, causing a breach of privacy; and lack of access to all the information available in a face-to-face visit may result in errors in medical judgment. In the event that you are mentally compromised, due to the variability of client location during Telemedicine, emergency services may fail to locate and treat you. In order to assist your emergency contact or emergency service providers, Practice will require you to identify your physical location prior to commencement of each Telemedicine session.
The Company offers providers the ability to sync a Google Calendar account with the calendar on the Company’s telehealth Platform. This requires access to read calendars and events for display inside of the Platform and to create and modify a calendar and calendar events in a connected Google account for Platform-originated events to be visible in the Google account holder's calendar. Additionally, the Google account email address is requested in order to display to the user which Google Account is synced with the platform account. The Company’s use and transfer to any other app of information received from Google APIs will adhere to Google API Services User Data Policy, including the Limited Use requirements.