Terms of Service
______Instructions to Client:
Welcome to EmmaFogt LLC. We look forward to your nutrition visit whether it be in person, over the phone or via skype. . Before we meet, please down load and complete the two nutrition forms from this website under “ Counseling Overview” and then click on “Counseling Forms”. The two forms are labeled: 1. Nutrition Assessment Form and 2. Three Day Food Records. Please print out and complete these forms for your first visit. On the date of our appointment we will review your completed forms together.
The first visit takes 1.5 hours and we will review your medical and nutrition history together. This will include laboratory work, medication, diet history, anthropometrics, calorie and macronutrients needs as well as vitamin and mineral status and Special Dietary needs. The initial visit affords the opportunity to discuss health concerns in depth, e.g. a full history investigating the health of all systems of the body from birth to present day. Multiple complaints can be addressed as well as mental & emotional imbalances.
You will receive a nutrition report you can share with your medical team within a week after your appointment via mail. During this appointment we will also make a plan of action for our follow-up visits together.
Office Location: The nutrition office is located at 14 S Bryn Mawr Avenue Suite 205, Bryn Mawr PA. There is plenty of parking in front of as well as behind the building.
Follow Up visits last from 30- minutes to 1 hour and can include one on one counseling, grocery tours or cooking, diet plans and recipe development. Follow Up Visits are scheduled on an “as needed” or package program basis depending on your preference. There is a 10% discount for 6 or more visits and a 20% discount for 12 or more visits. Lease see “Fees” for more information on payment.
All fees must be paid at time of service for in-house clients and in advance for phone and Skype clients. Cash, personal checks, or credit cards, Paypal, ApplePay are currently accepted. Checks should be written out to Emma Fogt LLC.
Initial Medical Nutrition Assessment (1.5 hours) $300.00
Dietary Surveillance & Counseling (1 hour) $200.00
Brief Dietary Surveillance & Counseling (0.5 hours) $100.00
Telephone Consultation per 15 minute increment $25.00
Nutrition Packages 6 Visits 10 % discount
Initial Assessment Plus 5 hours of Follow Up $1170.00
12 Visits 20% discount
Initial Assessment Plus 11 hours of Follow Up $2250.00
NOTE: The fee does not include any lab testing, procedures or follow up consults. Also, costs for labs does not include follow up visits to discuss them.
Workshop fees vary per topic
_____ Cancellation Policy:
Scheduled appointments may be cancelled without charge if notice is given at least 24 hours in advance. If notice is not given or is less than 24 hours prior to the scheduled appointment, you will be charged $50.00. I understand that I am responsible for personally making the $50.00 payment if I do not follow the cancellation policy.
All information you disclose both written and verbal is considered to be confidential information as outlined in the HIPAA notice of Privacy Practices. Every effort will be made to safeguard this information.
_____ Right to terminate or request that a colleague takeover nutrition therapy:
My dietitian has the right to end my treatment or speak with me about continuing my treatment with a registered and licensed dietitian colleague in the local area. Clients that live together or have a relationship may be asked to meet with two different dietitians. Every client situation will be evaluated on an individual basis.
Our services are not covered under insurance and we do not directly bill insurances from our office. Medical nutritional therapy is a reimbursable service covered by most medical insurance policies. However, it is highly recommended that prior to your first session you check the coverage offered by your carrier. A detailed invoice/receipt of payment will be provided at the end of each session. This document can be used to submit a claim for reimbursement to your insurance carrier by you. For those using insurance providers, you will receive an invoice with a diagnostic code to file with your insurance company. You will be responsible for payment of services at the conclusion of your nutrition session.
It is strongly recommended that you receive a referral from your physician for medical nutrition therapy services as the likelihood of reimbursement is greater with physician referral. I understand the billing policy of Emma Fogt LLC. I agree to be financially responsible for fees associated with my visits with a registered dietitian.
_______Communication (Texting/Calling/Emailing) Between Session:
I understand that texting, calling and emailing are not a secure or confidential form of communication with my dietitian between our sessions. My dietitian will discuss the appropriateness of texting and calling between our appointments during our session. I understand that my texts are held on a wireless server and my emails are held on Google and can be accessed at anytime; they are public records.
_____ Emails / Phone Calls
Short phone calls/email questions at no charge, but if the calls/emails becomes very frequent or longer than five minutes, we will charge at $25 per 15 minutes. We will make every effort to answer all email and phone calls within 24 hours of receiving them during business hours of Monday—Friday from 8:00am to 5:00pm.
_____ HIPPA Notice of Privacy Practices
I have received an electronic copy of the HIPPA (Health Insurance Portability and Accountability Act) Notice of Privacy Practices for Emma Fogt LLC. I understand that an updated copy of the HIPPA Notice of Privacy Practices is available online as well as at the Emma Fogt LLC offices.
_____ Waiver and Release for Nutrition Counseling:
The Registered and Licensed Dietitians of Emma Fogt LLC do not diagnose or treat disease. You should consult a physician for diagnosis and before undergoing any dietary or food supplement changes. Any recommendations you follow for changes in diet, including but not limited to the use of food supplements, are entirely your responsibility.
In consideration of my participation in the Nutrition Counseling, I hereby accept all risk to my health and of my injury or death that may result from such participation and I hereby release Emma Fogt LLC , from any liability to me, my personal representatives, estate, heirs, next of kin, and assigns for any and all claims and causes of action for loss of or damage to my property and for any and all illness or injury to my person, including my death, that may result from or occur during my participation in the Nutrition Counseling, whether caused by negligence of Emma Fogt LLC or otherwise. I further agree to indemnify and hold harmless Emma Fogt LLC from liability for the injury or death of any person(s) and damage to property that may result from my negligent or intentional act or omission while participating in the described Nutrition Counseling session.
All of Emma Fogt LLC’s communications including but not limited to handouts, nutrition counseling and website content offer no guaranteed cure for disease.
I HAVE CAREFULLY READ THIS AGREEMENT AND UNDERSTAND IT TO BE A RELEASE OF ALL CLAIMS AND CAUSES OF ACTION FOR MY INJURY OR DEATH OR DAMAGE TO MY PROPERTY THAT OCCURS WHILE PARTICIPATING IN NUTRITION COUNSELING AND IT OBLIGATES ME TO INDEMNIFY THE PARTIES NAMED FOR ANY LIABILITY FOR INJURY OR DEATH OF ANY PERSON AND DAMAGE TO PROPERTY CAUSED BY MY NEGLIGENT OR INTENTIONAL ACT OR OMISSION.
I have read and understand the above information.
Signature of responsible party:________________________________________ Print Name: _______________________________________________________ Date: ____________________________________________________________
© 2016 Emma Fogt, LLC