PATIENT CONTRACT — NON MEDICARE PARTICIPATING

PLEASE READ CAREFULLY PRIOR TO SIGNING:

I understand that Sharon Yirilli, MS, RD, CDN  is a registered dietitian.  She is  not a physician trained to diagnose and treat medical problems.  I give permission to the staff of  Sharon Yirilli, MS, RD, CDN to communicate with my physician in order to coordinate nutrition and health advice with my medical history.  I agree to keep the staff of Sharon Yirilli, MS, RD, CDN informed of any changes in my medical condition.

I also understand that the success I achieve in this program strongly depends on my ability to make permanent changes in my eating and exercise behavior.  I agree to follow-up with the staff of  Sharon Yirilli, MS, RD, CDN for scheduled counseling sessions.  I am aware that the staff of  Sharon Yirilli, MS, RD, CDN makes no claims or warranties regarding the results I should obtain under their direction.

I have been informed that Sharon Yirilli, MS, RD, CDN does not participate with Medicare and that I have the option of consulting with another dietitian, in the surrounding area, that does participate with Medicare.  I have read the introductory letter provided to me prior to this appointment, would like to enter into a consultation agreement with Sharon Yirilli, MS, RD, CDN and understand my financial responsibilities to Sharon Yirilli, MS, RD, CDN.

Successful medical nutrition therapy and self-care education involves behavioral change.  This change requires that I keep my scheduled appointments.  If I miss any pre-paid sessions without prior arrangements, it will be counted as a completed session as this time could have been used for other patients and encourages my compliance with this program.  No refunds or exchanges will be given at any time before and/or during any consultations or during any consultations or package programs.  If any of my appointments have prior authorization by my insurance company, I authorize payment by my insurance company to Sharon Yirilli, MS, RD, CDN.  Any balances not approved or covered by my insurance company are my financial responsibility.

I understand that any credit card deposits may be used to pay for unreturned loaned books, tapes or other borrowed property or to pay for any appointments canceled with less than 120 business hours (one business week-excludes Saturdays and Sundays) notice.

Sharon Yirilli, MS, RD, CDN maintains confidentiality of all patient issues unless we are given permission to communicate with your health care provider, by your signature below or if we feel your issues present a life-threatening situation.

Your signature indicates your understanding and acceptance of above policy and that you have received a copy of this agreement.

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Signature                                                                                               Date