Here is a breakdown of the documents you'll be signing:
Assignment of Benefits: This is an agreement between Foodsmart Nutrition Network and your insurance company or employer allowing us to communicate with each other. The main communication will be regarding payment. Because we see a variety of members with varying coverage levels, the language used in this form establishes that we can communicate openly and transparently with your insurance plan, your employer, or you to figure out how the visit will be covered. Questions about coverage? Please reach out to us at either 1-888-837-5325 or email us at email@example.com.
Notice of Privacy Practices: You have the right to know how your protected health information (PHI) may be used and disclosed securely as well as be informed around your legal rights. This document does exactly that; it explains how your PHI may be used and shared securely within specific HIPAA guidelines.
Consent to Call / Text: This gives you the option to allow us to call and text you about important information surrounding your appointment. You have the right to decline.
Health Information Exchange Opt-In: This gives you the option to allow us to appropriately access your PHI electronically and be a part of a network with your other health care providers. This exchange removes the chances of error, breaches, and inappropriate sharing of your PHI. It creates a fast and secure environment for both you and us and also creates a continuity of care that focuses on your health care as a whole. You have the right to decline.
Telehealth Informed Consent: Informed consent is standard across health care. As a patient, you have the right to receive information and ask questions about any services offered by us so that you can make informed decisions about your health. This form explains the services offered as well as any risks or benefits associated with the service. As a company that provides only virtual nutritional counseling visits, this form also explains the medium (video/phone) that the service is offered through as well as any kind of limitations surrounding telehealth.
Formulary Benefits Data Consent Form: This form just allows your Registered Dietitian to know what prescriptions are prescribed to you and to know what is covered by your insurance plan.
More questions? Please email