Allison Nutrtion Consulting has strict cancellation polices!
Your appoint time has been reserved for you. If you need to cancel or reschedule an appointment, you must give a minimum of 24 Hours advance notice (not 23 hours). If you do not notify us more than 24 hours in advance, you will be charged for your appointment. There are no exceptions! If you cannot make the appointment, we may be able to accommodate you with a phone appointment at that time or will try to accommodate you with another time. You will still be charged for the missed appointment. Exceptions are not made for illness, school or work schedule changes. In the case of officially advised driving restrictions, such as icy roads and when Nashville Public Schools have announced closure, you will not be charged for the missed appointment. Acknowledged______________
Our Approach: Treatment will focus on assisting you with nutrition knowledge, skills and tools for exploring your needs, behavioral strategies and support in order to reach a desired health goal.There is no definite length of treatment for individual sessions. Session numbers and frequency will be based on individual goals, needs and desire to engage in nutrition therapy.
CONFIDENTIALITY is maintained regarding all information except in emergency situations that involve serious harm to you or others, as in the case of suicide, child abuse or grave disability. Should we seek consultation from colleagues to improve my ability to help you, your name will be withheld. In all other situations, we will only release information regarding your treatment if I have your written permission.
YOUR PRIVACY IS IMPORTANT to us and reasonable measures will be taken to assure that communication by email and phone is secure.
Please confirm your preferred email address ________________________________________________________
Please confirm your preferred phone number____________________________________________
Full payment is advance is necessary to hold your appointment, unless we have your credit or debit card on file. Cash, check, and credit cards (Master Card/Visa) are accepted, as are Pay Pal payments - made at www.NanAllison.com at the bottom of the registration page.
Insurance: Allison Nutrition Consulting is in-network with Blue Cross Blue Shield of Tennessee and with CIGNA. Due to limited coverage of nutrition, varying plans, deductibles and co-pays, payment in full is due at the time of the appointment (unless prior arrangements have been made for insurance pre-authorization or verification billing.) Please note that the patient is still responsible for payment if the insurance company declines payment for any reason. _______________(initial) Insurance does not pay for any missed appointments, or late cancellations, therefore we request having yor credit card on file.
An itemized receipt on an insurance form with necessary codes will provided so that you may seek reimbursement from your insurance company. Seeking insurance reimbursement and submitting insurance reimbursement forms is entirely up to the client for whom services are provided (unless prior arrangements have been made for insurance pre-authorization or verification billing.) ________________INITIAL
Rates - Initial Assessment (75 Minutes): $175.00 Couples or Family (1.5-2 hours)- $275.00 - First Follow-Up Session/plan (60 Minutes): $150.00 Couples or family -- (1.5 hours – $225.00) - Follow-Up Sessions (45 Minutes):$120.00 - Weekly Follow-Up Sessions (30 Minutes): $80.00 - Phone and e-mail follow-up sessions $150.00 - used in three, 20-minute, or two, 30-minute increments - for a total of 1 hour. - Testing of Caloric Needs (Metabolism Testing): $50.00 (cost does not include
appointment or counseling, this is for test only) - Body composition test: $40 (cost does not include appointment or counseling) - Grocery Store/Home/RestaurantSessions: $200.00 - Food Sensitivity Testing: $395 – 1000.00 depending on test used. (cost does not
include appointment or counseling) Returned Check Policy:
In the event a check is returned for any reason, a $35.00 fee will be assessed.
I have read and understand the above policies:Signature__________________ Date___________________
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