Nutrition Coaching Privacy Consent

We require your consent to use and disclose your protected health information to carry out treatment, payment, and health care operations. If you would like a more detailed description of such uses and disclosures, please refer to the Notice of Privacy Practices.

You have the right to review the Notice of Privacy Practices before signing this consent form. The terms of the Notice of Privacy Practices may change from time to time. You can get a copy of the latest Notice of Privacy Practices here:
Notice of Privacy Practices

You have the right to request that we restrict how we use or disclose protected health information to carry out treatment, payment, or health care operations. We do not have to agree to such requests, but must honor the requests to which we agree.

You have the right to revoke this consent in writing, and the revocation will become effective except to the extent that we acted in reliance on your consent.

By filling out the form below, you hereby consent to our use of your protected health information to carryout out treatment, payment, and health care operations, and acknowledge receipt of a copy of this consent if requested.

    Note: E-mail contact is for your benefit only. Information is not shared without additional consent from you. However, e-mail exchange is not inherently secure.