Name
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First Name
Last Name
Date of Birth
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DD
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Email
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Phone
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Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Insurance #
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Current health insurance
Primary Account Holder
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First Name
Last Name
Your relation to Primary Account Holder
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Primary Care Physician
Physician Phone
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Reason for Appointment
Privacy Policy & Protected Health Information
Joyful Eaters LLC understand that protected health information about you and your health is personal and are committed to protecting health information about you. Your health information will be protected at all times and will be disclosed only under obligations following the federal HIPAA laws.
Rhode Island is a small state, and we want to be transparent about how we engage with clients outside of appointments. We are happy to smile or waive your direction, but discussions will not be initiated to protect your privacy and personal health information.
For any person or institution that is not directly related to care, payment of services or health care operations of this practice, all protected health information will be kept confidential UNLESS you sign a release authorization.
Financial Policy and Patient Responsibilities
It is your responsibility to understand your benefits before receiving services from us. Please understand that it you are responsible to pay for any amount that your medical insurance does not cover. A financial deposit in the form of a valid credit card will be required and kept on file to pay for services and fees.
Verify your health insurance coverage by asking the following questions:
• Is Amber Yui, RDN, an in-network provider for my current health insurance policy?
• Do I have nutrition benefits in my current plan?
• My diagnosis is ____________. Is this covered under my plan? (Preventative care is often covered and should be shared during the first appointment.)
• Is a referral required? (If so, contact your health care provider to have the referral faxed before the first appointment. Email joyful eaters to request the fax number and provide notification that a fax will be sent.)
• How many appointments are covered each year?
• Do I have a copay, coinsurance, or deductible?
• If I have a deductible, has my deductible been met? If not, what can I expect for my out-of-pocket expenses?
• If I have a coinsurance or copayment, what I can expect for my out-of-pocket expenses?
If a referral and/or prior authorization is required, obtaining this information is the patient’s responsibility.
Joyful Eaters, LLC is currently licensed in Massachusetts, Rhode Island, and Connecticut and provides submission for payment for Blue Cross Blue Shield health insurance plans through a professional billing consultant.
Joyful Eaters, LLC is also contracted with United, Aetna, Tufts, Cigna, and Neighborhood health insurance plans (Medicare and Medicaid are not covered), but submission for payment through health insurance is not provided and payment is charged directly to the client at the rate established by health insurance.
Private pay options are available. (Please note it is often more affordable to use health insurance.)
Sessions run 50 minutes with a standard rate of $200 for the first initial appointment and $150 for follow up appointments.
The first appointment is an opportunity to meet, connect, and brainstorm while viewing your medical records, habits and goals.
Follow up appointments are typically scheduled in 2-3 weeks intervals to answer questions and support your unique journey.
Late/Cancellation Policy
When you schedule an appointment, we reserve that time just for you. When you miss or cancel your appointment, it takes away precious time the provider could be spending with another client.
If you are more than 10 minutes late for an appointment you may be asked to reschedule, which will be considered a late cancellation and charged accordingly.
A late cancellation is any appointment that is not cancelled via email at least 48 hours before the appointment start time, not including weekends.
A late cancellation or no-show for an initial or first appointment will be charged a $50 fee with the credit card on file without the opportunity to reschedule.
Established clients who have completed their first appointment are eligible for one late cancellation or no-show fee waiver each calendar year. This courtesy is to be reserved for medical emergencies or circumstances beyond the client’s control.
Clients who have completed their first appointment and utilized their one late cancellation or no-show fee waiver for the calendar year will be charged $50 with the credit card on file for a subsequent late cancellation or no show.
If this occurs on any additional follow-up appointments for the calendar year the client will be charged the full private pay rate without the opportunity to reschedule.
A courtesy reminder is typically sent a day before an appointment, not for rescheduling purposes, but as a friendly reminder.
If the unpaid balance in your account becomes more than 30 days past due from the date of the invoice, a 1.5% monthly interest rate will be applied.
If a credit card transaction is declined, the payment will be reversed with an additional $30.00 service fee.
Please be advised you will not be able to book an appointment until a credit card is on file.
Electronic Payment Authorization...
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Please share the credit card you wish to use for any services rendered through this practice that are not covered by health insurance. We accept Visa or Mastercard credit cards as a form of payment, and receipt of payment can be submitted to HSA or FSA for reimbursement.
By checking the box below, you authorize that Joyful Eaters, LLC to charge your credit card. You also agree that your credit card can be charged for any session that is not canceled via email at least 48 hours prior to the scheduled session.
This authorization will remain in effect until it is cancelled in writing, and I agree to notify Joyful Eaters, LLC in writing of any changes in my account information or termination of this authorization.
You certify that you are the authorized user of this credit card and will not dispute these scheduled transactions with my bank or credit card company as long as the transactions correspond to the terms indicated in this authorization form. I acknowledge that credit card transactions could be linked to Protected Health Information.
Payment for any copays or balances will be charged with the credit card on file for clients with Blue Cross Blue Shield after the appointment has been processed by the health insurance.
Payment on the date of service will be charged with the credit card on file for clients with United, Aetna, Tufts, Cigna, and Neighborhood health insurance plans. Clients can submit the proof of payment for reimbursement with their health insurance.
Name on Card
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Credit/Debit Card Number
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Expiration Date
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Family-Based Appointment Policy
Appointment requests are reviewed and scheduled for the individual reviewing and acknowledging the policies above. Appointments are unable to be scheduled on behalf of friends or family members over the age of 18. If the individual is under 18, the first appointment must be with just the parent(s) and/or caregivers to discuss goals, family dynamics, and how best to support the minor. It is up to the discretion of the provider to include the minor in family or individual follow-up appointments as our experience has taught us that working with the parent(s)/caregiver first and then possibly the child in an age-appropriate way is best. For blended or separated parent(s) and/or caregivers who would both/all like to schedule appointments at the same time, this must be requested and approved via email 48 hours prior to the appointment start time.
Consent for Telehealth Consultation
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Recent health care legislation often provides coverage for nutrition services using telehealth.
I understand that my health care provider uses virtual telehealth for all appointments.
I understand that a telehealth appointment has potential benefits including easier access to care (such as saving time from traveling) and the convenience of meeting from a location of my choosing.
I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties.
I understand it is my responsibility to choose a space that is private and quite with stable internet connection that is free from distractions with the ability to enable both the camera and microphone features of the telehealth platform for clear communication.
I understand a courtesy appointment reminder will include a telehealth link to access the appointment prior to the appointment start time.
