you will sign a copy before your services. this is for your records.

PRACTICE POLICIES & COMMUNICATION GUIDELINES
1. I agree to reach out to the Southwest Dietitian Group to cancel or re-schedule appointments and will only contact my dietitian for administrative matters.

2. I understand that if I need to contact my dietitian between sessions, I will leave a message on our voicemail at telephone number 602-218-5278.

3. I understand that voicemail is checked once every 24 hours Monday through Saturday. Voicemail and e-mail are NOT checked on Sunday.

4. I understand the Southwest Dietitian Group cannot ensure the confidentiality of any form of communication through electronic media, including text messages. If you prefer to communicate via email or text messaging for issues regarding scheduling or cancellations, our team will do so. While we may try to return messages in a timely manner, we cannot guarantee immediate response and request that you do not use these methods of communication to discuss therapeutic content and/or request assistance for emergencies.
5. I will use e-mail for concise communication of administrative issues such as rescheduling an appointment only.

6. I will not use e-mail to discuss the course of treatment and/or diet planning. If I have a question about the course of my care, I need to schedule a session with the Southwest Dietitian Group through their scheduling portal, phone, or email. The dietitian has the discretion to address the questions received or wait until the next appointment or schedule an earlier session than agreed upon during correspondence.

7. I understand that Face-to-face sessions are highly preferable to phone sessions. However, in the event that you are out of town, sick or need additional support, phone sessions are available. If a true emergency situation arises, please call 911 or any local emergency room.
8. I agree that I will cancel or re-schedule my appointments no later than 24 business hours in advance. If I am unable to do so I agree to pay for the missed/canceled ($295 for an initial visit, $80 for a follow-up visit) appointment.

9. I understand that if my insurance policy changes I am required to let the Southwest Dietitian Group know and provide her with my updated insurance information. Failure to do may result in my insurance claims getting rejected and I will be responsible personally for those visits.

10. I understand that if my insurance policy changes I must re-verify my nutrition benefits for Medical Nutrition Therapy on my new policy as these benefits may have changed. Failure to verify my MNT benefits on my new plan may result in my insurance claims getting rejected and I will be responsible personally for those visits.

11. I understand there is a $30 fee for any returned check and I am willing to pay that.
12. I understand any outstanding payments for my nutrition visits must be paid within 30 days of my receipt of the invoice. Balances not paid within this time period will result in a 2% fee per month based on the total amount of the invoice.

13. I understand any outstanding balances with the Southwest Dietitian Group beyond 90 days will be sent to collections.

SOCIAL MEDIA AND TELECOMMUNICATION
Due to the importance of your confidentiality and the importance of minimizing dual relationships, we do not accept personal friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc). We believe that adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship. If you have questions about this, please bring them up when we meet and we can talk more about it.

MINORS
If you are a minor, your parents may be legally entitled to some information about your treatment. I will discuss with you and your parents what information is appropriate for them to receive and which issues are more appropriately kept confidential.

PATIENTS USING INSURANCE
I understand I am responsible for knowing how my insurance policy works and for presenting any necessary referrals or other documents to my healthcare provider. I am responsible for all co-payments, co-insurances and deductibles at the time of service. I am responsible for all costs of services provided if a valid referral from my doctor is needed, but not provided to the Southwest Dietitian Group, my insurance policy is not in effect, the Southwest Dietitian Group does not participate with my insurance. Payment is expected in full at the time of the visit.

I understand that if the claim is submitted and denied and action is required on my part as the patient, I will take action the insurance company needs within 30 days or I will be charged the full amount of the session.

I authorize the release of medical information necessary to process insurance claims to insurance companies or their agencies (including Medicare) for the purposes of filing and payment of medical claims. I authorize payment of medical benefits to the provider. I permit a copy of this release to be used in place of the original.

CANCELLATION POLICY
Our dietitians greatly value your time and theirs. Please remember to cancel or reschedule 24 hours in advance. You will be responsible for the entire fee if cancellation is less than 24 hours. This is necessary because a time commitment is made to you and is held exclusively for you.

Initial appointments last up to 60 or 90 minutes and follow-up appointments last up to 30 or 60 minutes. Initial appointments missed or canceled with less than 24 hours notice will be subject to a $195 cancellation fee for sixty-minute initial consults or $295 cancellation fee for ninety-minute initial consults. Follow-up visits missed or canceled with less than 24 hours notice will be subject to an $80 cancellation fee per thirty minutes schedule ($160 for a one-hour follow up).
If you are late for a session, you may lose some of that session time.

TERMINATION
Ending relationships can be difficult. Therefore, it is important to have a termination process in order to achieve some closure.

The appropriate length of the termination depends on the length and intensity of the treatment. The Southwest Dietitian Group dietitians may terminate treatment after an appropriate discussion with you and a termination process if the Southwest Dietitian Group dietitians determine that the treatment is not being effectively used or if you are in default on payment.

The Southwest Dietitian Group dietitians will not terminate the therapeutic relationship without first discussing and exploring the reasons and purpose of terminating. If treatment is terminated for any reason or you request another provider, the Southwest Dietitian Group dietitians will provide you with a list of qualified dietitians to treat you. You may also choose someone on your own or from another referral source.

Should you fail to schedule an appointment for one year, unless other arrangements have been made in advance, for legal and ethical reasons, the Southwest Dietitian Group dietitians must consider the professional relationship discontinued.