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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 Charges that are not completed due to invalid or outdated information will remain your responsibility.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. 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. Kaiser clients are required to check with their insurance plan that there is no preferred dietitian available with a reasonable wait time that meets state and federal law regarding acceptable wait times. By booking with a dietitian through Fay, Kaiser members confirm that no dietitians were available through their network that met regulatory requirements around provider availability; furthermore, Fay Health, Inc. reserves the right to file a formal complaint with any necessary parties to help support member advocacy efforts.
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.
Fay is committed to providing affordable, life-changing care from Registered Dietitians and amplifying the voices of our clients. When you receive care through Fay or any of our subsidiaries or partners, you gain access to essential health services at an affordable cost.
At times, initiatives by payors, federal, state, or local governments may jeopardize your ability—or that of others—to access affordable care. These initiatives can result from systemic misalignments or factors beyond our control. Should such circumstances arise, Fay guarantees your continued access to care at $0 out-of-pocket cost for services provided through Fay.
In exchange, you authorize Fay to advocate on your behalf to relevant stakeholders, which may include health insurance executives, elected officials, healthcare providers, or others deemed necessary by Fay. Advocacy activities might involve creating, editing, or delivering communications reflecting your experiences and perspectives, always with the goal of preserving affordable, accessible care.
By agreeing to our practice policies, you consent to Fay acting as your advocate, including creating content that represents your interests and experiences. You agree these actions are undertaken with your informed consent and do not constitute fraud, misrepresentation, or identity misuse. Additionally, you agree to indemnify and hold Fay harmless from any claims, damages, liabilities, or legal actions arising from these authorized advocacy activities.
As part of our ongoing commitment to support positive nutrition and wellness outcomes, Fay may offer users of our mobile application the opportunity to participate in a voluntary program to receive Virtual Items (the “Virtual Items Program”). By using the Fay mobile application, you agree to the terms of the Virtual Items Program as outlined below.
No Medical Advice
Participation in the Virtual Items Program is for general wellness engagement and is not a substitute for professional medical advice. Always consult your healthcare provider regarding any questions about your health or treatment plan.
IF YOU ARE EXPERIENCING AN EMERGENCY, YOU SHOULD DIAL “911” IMMEDIATELY
Earning Virtual Items
Users may earn virtual items known as “Virtual Items” by completing Eligible Actions within the mobile application. These Eligible Actions may include, but are not limited to, attending scheduled appointments, setting and completing daily wellness goals (e.g., logging meals, hydration, or activity), and engaging with other features of the app, as determined by Fay. The Eligible Actions may be changed from time to time, in Fay's sole discretion. The number of Virtual Items awarded for each action is determined solely by Fay and may change at any time without notice. Virtual Items may expire after periods of inactivity as determined from time to time.
Virtual Items may take the various forms in Fay’s mobile application which users earn for completing Eligible Actions. Virtual Items are intended solely to incentivize health-promoting behavior and enhance engagement. Virtual Items have no monetary or cash value and are not transferrable, refundable, or redeemable for cash.
Redeeming Virtual Items
Redeeming Virtual Items. You can redeem your Virtual Items for prizes offered at Fay’s discretion within the Fay mobile application (“App”), by navigating the App to view the Virtual Items balance in your account.
Once redeemed, the Virtual Items will be withdrawn from your account balance. Redeeming Virtual Items may require you to agree to additional terms and conditions that are established by the applicable provider or sponsor. Any additional terms and conditions will be presented to you in the App and you must agree to them before you can redeem your Virtual Items. Virtual Items are for use only in the App and have no cash value or other value outside of the App. Prizes may be fulfilled by third parties. In such cases, the third party will be solely responsible to you with respect to any redeemed prizes. Fay is not responsible for any redeemed prize.
Virtual Items may be redeemed through the app for the opportunity to earn various types of prizes, including but not limited to:
The availability, type, and value of prizes—and the number of Virtual Items required for redemption—are determined at Fay’s sole discretion and are subject to change, substitution, or discontinuation at any time without prior notice. Fay does not guarantee the continued availability of any specific prizes, tier, or redemption opportunity.
Modification and Termination
Fay reserves the right to modify, suspend, or terminate the Virtual Items Program, in whole or in part, at any time, with or without notice. This includes the right to:
Fay has no obligation to compensate you for unredeemed Virtual Items or other changes made to the Virtual Items Program.
Fay may manage, regulate, control, modify, or eliminate Virtual Items at any time, with or without notice. Fay may update the redemption value of Virtual Items at any time in its sole discretion, and may add new Virtual Items. Fay shall have no liability to you or any third party in the event that Fay exercises any such rights.
Legal Terms for Virtual Items Program
Limitation of Liability
To the maximum extent permitted by applicable law, Fay’s total cumulative liability to you for any claim arising out of or relating to the Virtual Items Program will not exceed one hundred dollars ($100). This limitation applies regardless of the legal theory on which the claim is based, including without limitation breach of contract, tort (including negligence), strict liability, or any other basis.
Binding Arbitration and Waiver of Jury Trial
Any dispute, claim, or controversy arising out of or relating to your participation in the Virtual Items Program shall be finally resolved by binding arbitration administered by the American Arbitration Association (“AAA”) under its Commercial Arbitration Rules. The arbitration shall be conducted in Chicago, Illinois. Judgment on the arbitration award may be entered in any court having jurisdiction thereof.
You and Fay agree that the arbitration shall be conducted in your individual capacities only and not as a class action or other representative proceeding, and you expressly waive any right to file or participate in a class action lawsuit or class arbitration.
YOU UNDERSTAND THAT BY AGREEING TO ARBITRATION, YOU ARE WAIVING YOUR RIGHT TO A JURY TRIAL AND TO LITIGATE YOUR CLAIMS IN COURT.
Indemnification
You agree to indemnify, defend, and hold harmless Fay and its affiliates, officers, directors, employees, and agents from and against any and all claims, liabilities, damages, losses, or expenses (including reasonable attorneys’ fees) arising out of or in any way connected with your misuse of the Virtual Items Program or your violation of these terms.
Governing Law
These terms and your participation in the Virtual Items Program shall be governed by the laws of the State of Illinois, without regard to its conflict of laws principles.
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.