Consent to Treat
Welcome to P.IampietroNutrition. LLC/Sweetwater Behavioral Heatlh & Wellness, PC.
Your agreement to the following terms and conditions is required for you/your child to receive professional services from me. If you do not agree, I will be glad to give you referrals to other providers.
You consent for yourself/your child to receive a comprehensive nutritional assessment. At the end of the evaluation, we will mutually decide if we will continue treatment together.
All communication and clinical treatment will be documented in the patient chart. Both the law and the standards of the profession require such. You are entitled to receive a copy of these records, unless I believe that seeing them would be emotionally damaging. If this is the case, I will be happy to provide the records to an appropriate health professional of your choice, or to prepare an appropriate summary instead. Because client records are professional documents, they can be misinterpreted and can be upsetting. If you wish to see the records, it is best to review them with me so that we can discuss their content.
Nutritional therapy/counseling remains an inexact science and no guarantees can be made regarding outcome.
There is no guarantee of confidentiality under the following conditions:
- If I suspect you/your child are/is in imminent danger of harm to self or others, or a child or elderly person is being abused or neglected (as I am a mandated reporter)
- If a court orders a release of information
- If you initiate a malpractice lawsuit, or a billing dispute with a financial institution
- If your insurance company requests to review your/your child’s case
- If you pay by credit card, my name will appear on your credit card statement
- If you do not pay your bill, your balance due statement (including diagnostic and procedural codes) may be sent to a collections agency or other responsible party
- Between me and my administrative staff, or colleagues with whom I consult professionally
You can review my HIPAA privacy practices.
You agree to pay professional fees as follows: Appointments are billed upon actual time of session;
$165 for 60 minute long initial evaluation
$ 70 for 30 minute follow-up appointment
$ 35 for a 15 minute check-in
If you self-pay at the time of service, I do offer a discount on these fees.
If you are insured by a Medicaid or CHIP plan, I do offer an Income Based Fee upon verification of you qualification of these medical insurance plans.
I will submit claims on your behalf as a courtesy, but there is no guarantee that your insurance will pay. You are responsible for full payment, whether your insurance company ends up paying partially, or not at all, for services rendered.
Upon request I can provide a Superbill, a detailed receipt that you can submit to your insurance company or HSA for reimbursement. This claim submission and reimbursement is between you and your insurance company and I make no guarantee of insurance coverage or payment.
For the packages or monthly membership services: Monthly memberships are paid at the start of your monthly services, a credit card needs to be kept on file and will be billed monthly; you consent to this billing as long as you are participating in this service level. Packages are billed in full at the initiation of the Package service. Services can be cancelled at any time, no refunds to be given if cancelled within a service month.
You agree to pay for any time spent in your or your child's care outside of session time on a prorated basis (unless otherwise detailed below). Unfortunately, insurance companies typically do not reimburse for this. Some examples include, but are not limited to:
- No shows/rescheduling with less than 24 business hours’ notice: full session charge. For example, if you or your child’s appointment is on Monday at 4pm, you will communicate your cancellation no later than the previous Friday at 4pm; if an appointment is on Tuesday at 10am, you will communicate no later than Monday at 10am.
- Phone calls, messages in the patient portal, voicemails, letters, video sessions and texts between me and: you, your child, or other physicians, therapists, teachers, family members, insurance companies, etc.
- Time spent obtaining prior authorizations
- Coordination of care for emergencies, hospitalization, intensive outpatient, residential treatment, rehabilitation, etc.
- All forms (insurance, worker’s compensation, school, employer; doctor’s notes, letters, or reports) and chart reviews not filled out in session
- Testimony in court, at depositions, administrative hearings, board reviews, and all time required for preparation and travel, whether requested by you or ordered by a court, board, government agency or other legal authority
- There is a fee, up to $50, for returned checks (which will also result in your credit card automatically being run for the balance due) and for credit card chargebacks that are unsubstantiated
You are financially responsible for all charges, whether or not:
- Insurance pays for any services
- We decide to proceed with treatment
- Treatment is successful, for which there cannot be any guarantee
You affirm you are an authorized user of the credit card whose number and expiration date supplied, and you do authorize its use for all fees incurred.
Depending on which office I see you in, I utilize a communication system through the electronic health record, DrChrono. This system works through your email and gives you access to a patient portal called OnPatient. I als.o work through Simple Practice which also gives you a patient access portal
By typing your signature below, you confirm you have read the above and agree to these terms and conditions.
Patient/Parent (if minor) sign Date