Intake Form -

Step 1 of 4

Name *

First

Last

Email *

Date of Birth *

Gender *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Marital Status *

Employment Status *

Have you had Nutrition or Diabetes Counseling and Education in the past? *

If so, when?

Describe your past experience.

Additional Comments

Acknowledgement

Please acknowledge that you have read and agree to the Notice of Privacy and Financial Practices. You also authorize the payment of medical and government benefits to your healthcare provider for services received. *

By submission of this form I acknowledge that I have read and agree the Notice of Privacy and Financial Practices

DANS-Diabetes and Nutrition Services, LLC
Notice of Privacy Practices
Effective Date: August 25, 2017
Here at DANS-Diabetes and Nutrition Services, LLC, we recognize that when you use DANS services, you
trust us with your information. We are committed to ensuring that your privacy is secured, consistent
with federal guidelines. We understand that your information is important to you as it is important for
us. This Privacy Policy helps you in understanding what information we collect and explains why we
collect information that you share with us and to what extent we make use of such information.
INFORMATION WE COLLECT
We may collect the following types of information:
-Your Name
-Your Phone Number
-Your Address
-Your Medicare or other Insurance Numbers
HOW WE USE THE INFORMATION WE COLLECT
Collecting the information that you share with us helps us (SPECIFY) and personalize your choices,
thereby providing you with better services. Specifically, we use this data for the following;
-Our internal data records
-Improve our services
-To contact you I response to enquiry and/or concerns
-Send you promotional emails about our services and other things that we consider might be relevant
To you
If you sign the intake form, you have agreed to allow us to use your information to better serve you.
We will never sell your information to third parties unless we have your permission.
Any personal information that we have about you is stored at DANS under lock and key.
We at DANS-Diabetes and Nutrition Services, LLC, believe in open communication. If you have any
questions and/or concerns about this policy, please contact us at 501-703-0882 or email us at:
info@dansnutritionhealth.com.
FINANCIAL POLICY
The undersigned agrees, whether he or she signs as a guardian or as a patient, that in consideration of
the services to be rendered to the patient, he or she hereby individually obligates him/herself to
promptly pay the account of Jennifer I. Hall, MS, RDN, LDN, CDCES of DANS-Diabetes and Nutrition
Services, LLC. Provisional credit may be allowed for confirmed insurance benefits assigned to Jane Doe.
All such provisional credits are subject to collections.
The office will file your insurance only if Jennifer I. Hall is a provider under your insurance plan, HMO,
PPO. It is your responsibility to provide the necessary insurance information to do so, including
authorizations. If this information is not provided at time of visit you will be required to make payment.
If Jennifer I. Hall is not a provider under your insurance plan the office will not file your insurance. Your
insurance is a contract between you and your insurance carrier and does not guarantee payment for
nutrition services and/or payment to Jennifer I. Hall. This office cannot become involved in disputes
regarding claims, deductibles, co- payments, non-covered charges, or other denials of payment. The
office is required to collect any patient responsibility, as this is part of our HMO/PPO contract.
If you sign the form, you agree that you pay any deductible and co-payment or co-insurance as
determined by your insurance plan. You are responsible for any amounts not covered or payable by
your insurance. If your insurance denies any part of your claim, you agree to be responsible to pay the
full balance.
If you have any questions regarding your insurance coverage please direct them to your insurance
representative.
If you fail to pay your account, you will be responsible for any collection fees incurred. This includes a
10% processing fee if your account has to be placed with a third party for collection.
APPOINTMENT-SCHEDULE
Your appointment consists of an individual counseling session. In order to continue to offer the ultimate
in patient care we need your commitment. We request 48 hours’ notice from our patients when
canceling or rescheduling an appointment. If you fail to provide us with advance notice of a cancellation,
our staff is unproductive during that reserved time slot. This will ultimately impact the kind and cost of
the service we provide.
In order to contain cost if anyone fails to notify us with less than 48 hours in advance of their scheduled
appointment, a rescheduling fee of $25.00 will be charged to their account (not your insurance
company). This policy applies to all clients regardless of insurance coverage and is approved by all
HMO’s.
Please note lack of insurance referrals will not be considered a valid excuse as sufficient reminders are
given for follow-up referrals. Ultimately, it is the patient’s responsibility to be aware of his/her insurance
and referral coverage. Please remember we make every effort to remind you of your appointment with
written text message. The mission of DANS-Diabetes and Nutrition Services, LLC is to improve the
nutritional health of our clients, not collecting rescheduling fees. Please assist us in maintaining good
service.
ACKNOWLEDGEMENT:
Your submission of the intake form is acknowledging that:
I have read and understand the financial policy described above. I agree to pay, promptly and in full,
any amounts due to the provider, including co-payments, deductibles, and amounts due for noncovered or services that are not paid by your insurance.

Primary Care Physician & Insurance Information

Insurance Carrier Information

Dependent & Subscriber Information

Acknowledgement