Nutritional Services Authorization for Treatment

Patient Information

Name: _____________________________ Date of Birth: _______________ Address: ___________________________ Phone: ____________________

Authorization for Treatment

I, _________________________, hereby authorize [Practice Name] and its registered dietitians/nutritionists to provide nutrition counseling and medical nutrition therapy services. I understand and acknowledge the following:

Services

• Comprehensive nutrition assessment
• Personalized meal planning
• Nutrition education and counseling
• Regular progress monitoring
• Coordination with other healthcare providers

Financial Agreement

• I understand that I am responsible for all charges not covered by insurance
• Payment is expected at the time of service unless prior arrangements have been made
• Cancellation requires 24-hour notice to avoid charges

Privacy & Records

1. I acknowledge receipt of the Notice of Privacy Practices
2. I authorize the release of my nutrition-related medical information to:
   • My primary care physician
   • Other healthcare providers involved in my care
   • My insurance company (if applicable)

Consent for Treatment

I understand that:

• Nutrition therapy is a collaborative process
• Results may vary based on adherence and individual factors
• This authorization remains valid until revoked in writing

Patient Signature: _________________ Date: _____________

Practitioner Signature: _____________ Date: _____________

Office Use Only

Chart #: _____________ Insurance Verification: □ Complete □ N/A Initial Assessment Date: _____________