Healthcare Nutrition Documents

HEALTHCARE NUTRITION DOCUMENTS

Patient Information

Patient Name:    Date of Birth:

Female   Male   Non-binary/Other   Prefer not to answer

Insurance Information

Medical & Nutrition History

Dietary Intake & Assessment

Goals, Care Plan & Follow-up

Informed Consent for Nutrition Services

I hereby request and consent to nutrition assessment, medical nutrition therapy, counseling, education, and related services provided by qualified nutrition personnel. I understand that nutrition services are intended to identify nutritional needs, provide individualized recommendations, and establish a care plan. I acknowledge that:

1. Services may include dietary history review, anthropometric measurements, dietary counseling, written care plans, and coordination with other healthcare providers.
2. Benefits may include improved nutritional status, symptom management, and support for medical conditions; results are not guaranteed and vary by individual.
3. Risks are minimal but may include transient discomfort from discussing weight or eating behaviors, and potential changes in laboratory values as dietary changes occur.
4. I may withdraw consent or discontinue services at any time without affecting other medical care, but I understand recommendations may be discontinued if I do not follow scheduled visits or clinician instructions.

I authorize my nutrition provider to consult with my other healthcare providers as necessary for coordination of care. I understand that telehealth sessions may be offered and consent to telehealth consultations if elected by the provider: I consent to telehealth services

I acknowledge that I have had the opportunity to ask questions about the nature, expected benefits, and potential risks of nutrition services and that my questions have been answered to my satisfaction.

Authorization to Use and Disclose Health Information (HIPAA — Nutrition Records)

I authorize the release of my nutrition and related health information as described below. I understand this authorization is voluntary and that my treatment is not conditioned on signing it except where permitted by law.

Information to be disclosed (check all that apply):

Nutrition assessments and evaluations   Care plans and recommendations   Relevant lab results and measurements   Complete nutrition record

I understand that I may revoke this authorization in writing except to the extent that action has already been taken in reliance on it. I understand that information disclosed pursuant to this authorization may be redisclosed by the recipient and may no longer be protected by privacy laws. A copy of this authorization is as valid as the original.

Acknowledgment of Privacy Practices & Financial Policy

I acknowledge that I have been offered the practice’s Notice of Privacy Practices and that I understand my rights regarding protected health information. I understand my financial responsibilities for services rendered, including applicable copayments, deductibles, and fees for missed appointments as described by the provider.

I acknowledge receipt of privacy practices and financial policies

Patient Certifications

By signing below I certify that the information I have provided is accurate to the best of my knowledge. I consent to the provision of nutrition services described above and authorize release of protected health information as indicated. I understand that I have the right to ask questions and to refuse any recommended component of care.

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