Ellen Nutrition LLC
Julie Ellen Caballero RD, MPH
Phone: 678 256 4162
Email: julieellennutrition@gmail.com
Nutrition Counseling Client Agreement
Effective 7/25/2022 Updated 11/28/2022
General Information
A registered Dietitian does not diagnose diseases and disorders. Nutrition counseling includes education on nutrition, lifestyle, and supplements. I acknowledge I am responsible for providing accurate information regarding my medical history and symptoms, and any medications and supplements that I am taking. I acknowledge my responsibility in notifying my Medical Physician prior to making any changes in my nutrition, lifestyle (including exercise), and my decision in taking any supplements. I acknowledge full responsibility for any risks associated with making changes in my nutrition and lifestyle. I acknowledge full responsibility for any risks associated with researching brands of supplements and choosing to take certain brands of supplements. I acknowledge that Ellen Nutrition LLC, can conclude providing nutritional counseling services to me at any time, and when appropriate provide a referral. I acknowledge that Ellen Nutrition LLC, is not liable for my health outcomes and safety. I acknowledge that I am fully responsible for my health outcomes and safety.
Appointments
Appointments must be cancelled within 24 hours of the scheduled appointment. If the appointment is not cancelled/rescheduled within 24 hours, you will be charged a $15 fee. An appointment will be cancelled if you do not arrive for in person or virtual appointments within 15 minutes of the appointment, and you will be charged a $15 fee. This fee must be paid before you reschedule another appointment.
Payment Policy for self-pay clients (non-insurance covered)
Ellen Nutrition LLC is not a preferred provider for Medicare or any insurance networks. Payments are due prior to the appointment. Payments may be cash, check, or credit card. If checks are returned, you will be charged a $15 fee. This fee must be paid before rescheduling another appointment. I agree to be financially responsible for payment of services.
Cost of Services
If there is a change in the cost of services, you will be notified ahead of time.
Nutrition counseling for 1 client:
Initial appointment 1 hour $40
1 hour follow up $40
30 minute follow up $20
During an appointment if you would like to extend the amount of time of the appointment, there will be a charge of $10 for each increment of 15 minutes.
Nutrition counseling for Group of 2 or more each person in the group will be charged:
Initial appointment 1 hour $40
1 hour follow up $40
30 minute follow up $20
During an appointment if you would like to extend the amount of time of the appointment, there will be a charge of $10 for each increment of 15 minutes.
Communication
Voicemail and email messages will be returned within 2 business days. Email may not be a secure way to send personal health information. You acknowledge if you request Ellen Nutrition LLC, to send you personal health information via email, or if you send personal health information via email to Ellen Nutrition LLC, that this may not be a secure method of communication. More secure ways to send personal health information are via in person, phone, or attaching documents with personal information on your Carepatron portal.
Consent for telehealth consultation
I understand that my health care provider wishes me to engage in a telehealth consultation.
My health care provider explained to me how the video conferencing technology that will be used to affect such a consultation will not be the same as a direct client/health care provider visit due to the fact that I will not be in the same room as my provider.
I understand that a telehealth consultation has potential benefits including easier access to care and the convenience of meeting from a location of my choosing.
I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my health care provider or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.
I have had a direct conversation with my provider, during which I had the opportunity to ask questions in regard to this procedure. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand.
Consent to use the telehealth by carepatron service
Telehealth by Carepatron is the technology service we will use to conduct telehealth videoconferencing appointments. It is simple to use and there are no passwords required to log in. By signing this document, I acknowledge:
Telehealth by Carepatron is NOT an Emergency Service and in the event of an emergency, I will use a phone to call 911.
Though my provider and I may be in direct, virtual contact through the Telehealth Service, neither Carepatron nor the Telehealth Service provides any medical or healthcare services or advice including, but not limited to, emergency or urgent medical services.
The Telehealth by Carepatron Service facilitates videoconferencing and is not responsible for the delivery of any healthcare, medical advice, or care.
I do not assume that my provider has access to any or all of the technical information in the Telehealth by Carepatron Service – or that such information is current, accurate or up to date. I will not rely on my health care provider to have any of this information in the Telehealth by Carepatron Service.
To maintain confidentiality, I will not share my telehealth appointment link with anyone unauthorized to attend the appointment.
By signing (Client or client’s parent/guardian must sign) (Parent or legal guardian must sign if patient is under 18 years of age.) this “Nutrition Counseling Client Agreement Form” I certify:
I have read or had this form read to me, and I fully understand its contents.
I fully understand the risks and benefits of a telehealth consultation.
I have been given ample opportunity to ask questions and my questions have been answered to my satisfaction.
I am financially responsible for payment of service.
I acknowledge that I am fully responsible for my health outcomes and safety.
I acknowledge that if I request Ellen Nutrition LLC, to send me personal health information via email, or if I send personal health information via email to Ellen Nutrition LLC, that this may not be a secure method of communication.
I acknowledge that I have received a copy of Ellen Nutrition LLC’s “HIPPA Notice of Privacy Practices.”
Printed Patient or Parent/Guardian Name: ____________________________________
Patient or Parent/Guardian Signature: __________________________Date: _______________