Patient Forms

Confidentiality Policy

Your privacy is very important, and all sessions will be held in strict confidence. A release form will be used to obtain permission to speak with your physician and/or other healthcare providers regarding your treatment. You are not required to sign the release.

Billing and Insurance Coverage Policy

Payment is due before the time of service or immediately following services and will be charged by a HIPAA-compliant platform called Ivy Pay®. Credit, debit, HSA and FSA cards are acceptable forms of payment. A receipt can be provided for services rendered. Shira Evans Nutrition LLC does not accept insurance at this time but can provide you with a monthly Superbill that you can submit to your insurance company. Insurance companies may
or may not cover nutrition counseling.

Cancellation and Refund Policy

Time has been specifically reserved for your nutrition appointment. If you need to cancel or reschedule your appointment, please do so by contacting Shira Evans Nutrition LLC via e-mail or phone with a minimum of 24-hours notice from your appointment time. Appointments not canceled within this time frame will be charged at 100 percent. Your cooperation with this policy is greatly appreciated.

Lateness Policy

Appointments will be held for 15 minutes only. If you arrive within this time period, you will be seen but your appointment time will not be extended. After 15 minutes, your appointment will be forfeited, and you will be charged 100 percent of the session fee (if prepaid, a refund will not be given).

Your signature below indicates that you understand and agree to the Office Policies.

As this notice describes how medical information about you may be used and disclosed, as well as how you may obtain access to such information, please review it carefully. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal Program. It requires that all medical records and other individually identifiable health information used or disclosed by Shira Evans Nutrition LLC in any form (whether electronically, on paper, or orally) are kept properly confidential. This Act gives you, the patient, new rights to understand and control how your health information is used.

HIPAA provides penalties for covered entities that misuse personal health information. As required by HIPAA, Shira Evans Nutrition LLC has prepared this explanation of how Shira Evans Nutrition LLC is required to maintain the privacy of your health information and how Shira Evans Nutrition LLC may use and disclose your health information.

Shira Evans Nutrition LLC may use and disclose your medical records only for the following purposes: treatment, payment, and healthcare operations.

“Treatment” means providing, coordinating, or managing healthcare and related services by one or more healthcare providers. An example of this would include a physical examination. “Payment” means such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities, and utilization review. An example of this would be sending a bill for your visit to your insurance company for payment. “Health Care Operations” include the business aspects of running the practice of Shira Evans Nutrition LLC, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis, and customer service. An example of this would be an internal quality-assessment review.

Shira Evans Nutrition LLC may create and distribute de-identified health information by removing all references to individually identifiable information. Shira Evans Nutrition LLC may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services, which may be of interest to you.

Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing, and Shira Evans Nutrition LLC is required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization.

You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to Shira Evans Nutrition LLC:

• The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. Shira Evans Nutrition LLC is not however, not required to agree to a requested restriction. If Shira Evans Nutrition LLC does agree to a restriction, Shira Evans Nutrition LLC must abide by it unless you agree in writing to remove it.
• The right to reasonable requests to receive confidential communication of protected health information from Shira Evans Nutrition LLC by alternative means or at alternative locations.
• The right to inspect and copy your protected health information.
• The right to amend your protected health information.
• The right to receive an accounting of disclosures of protected health information.
• The right to obtain a paper copy of this notice from us upon request.

Shira Evans Nutrition LLC is required by law to maintain the privacy of your protected health information and to provide you with notice of our legal duties and privacy practices with respect to protected health information.
This notice is effective as of 08/09/2022, and Shira Evans Nutrition LLC is required to abide by the terms of the Notice of Privacy Practices currently in effect.

Shira Evans Nutrition LLC reserves the right to change the terms of our Notice of Privacy Practices and to make the new notice provisions effective for all protected health information that we maintain. We will post, and you may request a written copy of a revised Notice of Privacy Practices from this office.
You have recourse if you feel that your privacy protections have been violated. You have the right to file a written complaint with our office, or with the Department of Health and Human Services, Office of Civil Rights, about violations of the provisions of this notice or the policies and procedures of our office. We will not retaliate against you for filing a complaint.
Please feel free to contact us for more information. A complaint to the Secretary should be filed within 180 days of the occurrence or action that is the subject of the complaint.