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 Charges that are not completed due to invalid or outdated information will remain your responsibility.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. If at any time you want to discuss your financial obligations, please reach out to us at 630-635-5950.
Notice of Privacy Practices
Telemedicine Informed Consent
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.