Rebekah DeWitt, MS, RDN, LD
You have just taken a very positive step in deciding to seek dietary and lifestyle changes. I am happy that you have selected me to guide you on this journey and I want you to feel comfortable with the consultation process. To accomplish this, I have prepared this introduction.
I have 3 years of experience as a registered dietitian. My education accomplishments include a bachelor’s of science in nutrition and dietetics and a master’s of science in nutrition and dietetics. I have previously worked with a cardiovascular clinic, created a weight loss program for clients of the Alabama Pain Center as well as clients of Alabama Bariatrics and Minimally Invasive Surgery, and taught undergraduate nutrition courses for Oakwood University. In addition, I have served as secretary for the North Alabama Dietetic Association and State Policy Representative for the Alabama Dietetic Association. My vision in this client-dietitian relationship is to assist you as far as it is in my ability to accomplish your health goals.
Although this document can seem long and complex, it is very important that you read it carefully and complete all sections before our first session. We can discuss any questions you may have at that time. Please continue to ask any questions or voice concerns throughout the course of treatment so that our professional relationship will be open and satisfying for all. When you sign this document, it will also represent an agreement between us. You may revoke this Agreement in writing at any time.
Initial nutrition appointments are 50 minutes in duration, and follow up appointments are 30 minutes. After your intake appointment, future appointments will be scheduled. I see clients by appointment only. To change or cancel an appointment, I require at least a 48-business hour notice for any cancellations. This will help me to schedule those waiting for appointments and for you to avoid being charged for the time that was reserved for you. Clients who cancel without a 48-hour notice or do not attend their appointment will incur a cancellation/no show fee. If your appointment is on a Monday, and you leave a message on the machine over the weekend, that does not constitute 48-hour notice. No exceptions will be made for emergency situations. Insurance does not pay for late cancellations or missed appointments.
Adult Intake Packet for Nutrition Services 2
If you experience an emergency during or after hours, you should seek immediate help by calling 911, Helpline (539-1000 or 539-3424), your primary care physician, or one of the hospital emergency rooms for assistance as needed.
My policy is full payment at the time services are rendered. I accept cash, checks, and credit cards. I do not accept health savings or flex spending cards. I do not bill for insurance. I can provide a super bill receipt with my provider information which you may be able to submit for reimbursement depending on your insurance policy. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require the disclosure of otherwise confidential information. In most collection situations, the only information released regarding a client’s treatment is his/her name, the nature of services provided, and the amount due. If such legal action is necessary, its costs will be included in the claim.
Client Credit Card Information
I require this information for you to make an initial appointment with me. This information will be kept strictly confidential. I will only use this information to charge for late notification or missed appointments. If you do not provide this information, you will need to seek treatment elsewhere.
Name on card: _________________________________
Card number: __________________________________
CVS number: __________________________________
Expiration date: ________________________________
Billing zip code: ________________________________
If a letter or other special correspondence is requested/required, preparation time for processing the request may be billed at my usual hourly rate. Review of past therapeutic documentation (i.e. treatment, history, discharge summaries, etc.) letters, journals, or personal writings forwarded to me for reading and telephone correspondence to and from authorized sources may be subject to billing at my usual hourly rate and is regarded as the client’s personal financial responsibility (not covered by insurance). Clients are discouraged from having me subpoenaed. All court related work is billed at $220/hour. This is a non-insurance charge. The client will be responsible for payment which includes: phone calls, filing documents with the court, pre-court record review, pre-court case formulation, depositions, consultations with attorneys, court appearances, in court (testimony) time, and time for travel and “waiting,” and total time out of the office (departure until return). The minimum charge for a court appearance is $1500. A retainer of $1500 is due in advance. If a subpoena or notice to meet attorney(s) is received without a minimum of 48-hour notice there will be an additional $250 “express” charge. Also, if the case is reset with less than 72 business hours notice, the client will be charged $500 (in addition to the retainer of $1500). Even though the client is responsible for the testimony fee, it does not mean that the clinician’s testimony will be solely in their favor. The clinician can only testify to the facts of the case and to their professional opinion. Clients will be asked to sign a release of information and agreement for court appearances, if these services are required.
I, (your name) ___________________________________ understand that Rebekah DeWitt is not in network for any private insurance providers and does not file insurance. Rebekah DeWitt cannot determine if or what I will be reimbursed for dietitian services. That is between my insurance provider and me. If I plan to file an insurance claim on dietitian services, I will contact my insurance provider before my first visit to verify my mental health benefits as pre-certification or authorization may be required. I will be provided a complete itemized statement that contains all necessary information needed so that I can bill my insurance directly.
Adult Intake Packet for Nutrition Services 3
I have been given the opportunity to discuss these policies and to ask for clarification. I have read and agree with all of the above information. I understand that I will be responsible for charges and will pay for services as rendered regardless of amounts, if any, reimbursed to me by my insurance company. My signature below constitutes an understanding of and agreement to the terms and conditions above.
___________________________________________ ___________________________ Client or Legal Guardian’s signature Date Clinical Record
Professional laws and standards require that a clinical record of dietitian services be maintained for all treatment provided. The client record remains the property of the clinician. Clients have the right to request that a record is amended; to request restrictions on what information from your clinical record is disclosed to others; to request an accounting of disclosures that you have neither consented to nor authorized; to determine the location to which protected information disclosures are sent; and to have any complaints you make about these policies and procedures recorded in your records. I am happy to discuss any of these rights with you.
Confidentiality and Disclosure Statement
The confidentiality of dietetic services I provide is protected by professional ethics and law. Unless you grant written permission, I will neither inform anyone that you are receiving services, nor will I disclose personal information provided. Legal and ethical exceptions exist. If you would like for information from your clinical record to be sent to a third party (i.e., physician, therapist, attorney, etc.) you must first sign a Release of Authorization form provided by our office. A fee may be required before records are forwarded.
Limits On Confidentiality
The law protects the privacy of all communications between a client and a clinician. In most situations, I can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements. There are other situations that require that you provide written advance consent. Your signature on this Agreement provides consent for those activities, as follows:
- I may occasionally find it helpful to consult other health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my client. The other professionals are also legally bound to keep the information confidential. If you don’t object, I will not tell you about these consultations unless I believe that it is important to our work together. I will note all consultations in your Clinical Record.
- You should be aware that I employ administrative staff. In most cases, I need to share protected information with these individuals for both clinical and administrative purposes, such as scheduling and billing. All staff members have been given training about protecting your privacy and have agreed not to release any information outside of the practice without my permission.
- I also may have contracts with other businesses such as an accounting firm or attorney. I have a formal business associate contract with these businesses, in which they promise to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I can provide you with the names of these organizations and/or a blank copy of this contract.
Adult Intake Packet for Nutrition Services 4
- If a client threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her, or to contact family members or others who can help provide protection.
There are some situations where I am permitted or required to disclose information without either your consent or authorization:
- If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the dietitian-patient privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information.
- If a government agency is requesting the information for health oversight activities, I am required to provide it for them.
- If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client in order to defend myself.
- If a client files a worker’s compensation claim, I may disclose information relevant to that claim to the client’s employer or the insurer.
There are some situations in which I am legally obligated to take actions, which I believe are necessary to attempt to protect others from harm, and I may have to reveal some information about a client’s treatment.
Adult Intake Packet for Nutrition Services 5
I hereby acknowledge that these limitations on confidentiality have been read by me and/or explained to me and I agree to abide by them. I have been given the opportunity to discuss these concepts and conditions and to ask for clarification. I understand that my consent to treatment may be withdrawn by me at any time without prejudice.
___________________________________________ ___________________________ Client or Legal Guardian’s Signature Date Client’s Rights
You, the client, have the right to: • Receive respectful treatment that will be helpful to you without discrimination • Be informed about techniques, intervention strategies and procedures, or any aspect that might not be clear or understood regarding treatment • Be informed and inquire about diagnosis, methods of assessment, and the goals of treatment • Accept or decline treatment (except in emergency situations or when ordered by a judge or Federal/State authority) • Seek alternative dietetic services and be provided with an appropriate referral • Discuss, question, and participate in hospital, residential placement, half-way or quarter-way treatment decisions • Ask for and receive information about the clinician’s qualifications, including license, education, training, experience, membership in professional groups, special areas of practice, and limits of practice • Refuse to answer any question or give any information you choose not to answer or give • Know if your clinician will discuss your case with others • Ask that the clinician inform you of your progress • A safe treatment setting, free from sexual, physical, and emotional abuse. In a professional relationship, sexual intimacy between a therapist and a client is never appropriate • Report suspected immoral or illegal behavior
Smoking is not allowed inside the facilities. Possession of illegal substances, alcohol, firearms, or weapons is prohibited on our premises. Being under the influence of drugs or alcohol is prohibited. If I suspect that you are in violation of these rules, or any other laws, you will be asked to leave, and /or appropriate authorities will be notified.
Client or Legal Guardian’s signature Date
Adult Intake Packet for Psychotherapy 6
Client Contact Information
Client’s Name___________________________________________ Date _____________________ Client Age___________ Sex______ Ethnicity _______________ Date of Birth _________________ Home Address ____________________________________________________________________ City__________________________________ State ______________________________________ Email ______________________________________ Cell Phone __________________________ Home Phone ___________________ Work Phone __________________ (Circle preferred contact #) *OK to leave a voicemail at preferred contact # regarding appointments? Y N How did you hear about us:____________________________________________________________ Other family members seen here:_______________________________________________________ In case of an emergency please contact:__________________________________________________ Relationship:________________________________ Telephone: _____________________________
Reason for Seeking Treatment:_________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ Approximately how long have you had the current problem or concern? ________________________ How was the decision made to come in now? _____________________________________________ __________________________________________________________________________________ In what ways have you attempted to cope with this problem or concern? ________________________
Have you lost or gained an unusual amount of weight lately Y N Lost or Gained ____ lbs