Photograph by Audrey Anastasia Audrey L. Anastasia, DrPH, RD

Office Policies

Thank you for choosing Audrey L. Anastasia, DrPH, RD as your health care provider for medical nutrition therapy. Because some of our patients have had questions regarding patient, clinician and insurance responsibility for services rendered, we have developed this policy. Please read it, ask us any questions you may have, and sign in the space provided. A copy will be provided to you upon request. Your signature below, or checking the Terms of Consent box at the onset of your telehealth visit, indicates you are aware of and agree to our office policies as noted below.

1. Privacy Practices. We care about your privacy. The information we collect about you is private. Only people who have the need and legal right may see your information. Unless you give us permission in writing, we will only disclose your protected health information (PHI) for the purposes of treatment, payment, healthcare operations and when we are required by law to do so. Please review our Health Insurance Portability and Accountability Act (HIPAA) Notice of Privacy Practices.

HIPAA Notice of Privacy

2. Insurance. We participate in most insurance plans. If you are not insured by a plan we do business with payment in full is expected at each visit. If you are insured by a plan we do business with, but don’t have an up-to-date insurance card, payment in full for each visit is required until we can verify your coverage. Knowing your insurance benefits is your responsibility. Please contact your insurance company with any questions you may have regarding your coverage.

3. Co-payments and deductibles. All co-payments and deductibles must be paid at the time of service. This arrangement is part of our contract with your insurance company. Failure on our part to collect co-payments and deductibles from patients can be considered fraud. Please help us in upholding the law by paying your co-payment at each visit.

4. Non-covered services. Please be aware that some – and perhaps all – of the services you receive may be noncovered or not considered reasonable or necessary by your insurer. Some Insurance companies may require precertification or authorization for services rendered. It is your responsibility to acquire the appropriate approvals before your office visit. In the event that your insurance carrier denies coverage or benefits for either of these reasons, you will be responsible for payment of the visit.

5. Proof of insurance. We must obtain a copy of your current valid insurance to provide proof of insurance. If you fail to provide us with the correct insurance information in a timely manner you may be responsible for the balance of a claim. If your insurance changes, please notify us before your next visit so we can make the appropriate changes to help you receive your maximum benefits.

6. Missed appointments. Our policy is to charge $50 for missed appointments as a result of not showing for your scheduled in-person or telehealth appointment. Late cancellations result in a charge of $25 and are for appointments not canceled within a reasonable amount of time – at least 24 hrs notice. These charges will be your responsibility and billed directly to you. Please help us to serve you better by keeping your regularly scheduled appointment as this time has been set aside just for you. Two missed appointments as a result of late cancellations will result in you being discharged and referred elsewhere.

7. Release of Health Care Information. I hereby authorize the Release of Health Care Information for the sole purpose of communicating with my other medical providers re: my treatment. This includes phone calls and copies of office notes.

8. Billing Authorization. I authorize the Clinicians at Manchester Obstetrical Associates, PA, and Emax Medical Billing, LLC to release all information required to process my insurance claim. I authorize my insurance company to make payments directly to Audrey L. Anastasia, DrPH, RD, LLC. All billing inquiries are to be directed to Emax Medical Billing at (603) 924-7797 or toll free at (877) 924- 7797.

Our practice is committed to providing the best treatment to our patients. Please let us know if you have any questions or concerns.

I have read and understand the office policies and agree to abide by its guidelines.

I acknowledge that I have reviewed Audrey L. Anastasia, DrPH, RDs Notice of Privacy Practices.

Your signature below or checking the Terms of Consent box at the onset of your telehealth visit, indicates you are aware of and agree to our office policies as noted below.

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Print Name Date of Birth

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Signature of Patient or Responsible Party Date