Patient Acknowledgement

  • Notice of Privacy Practices

    The Notice of Privacy Policy is available for download by clicking the link below. Communication with other health care providers: For the purposes of my health care and/or billing I agree that Nourish Your Life may communicate with my health care practitioners and/or insurance. I also authorize Nourish Your Life to send electronic communication which may contain protected health information (PHI) to either my e-mail account or personal health record.

    Click here to view our Notice of Privacy Practices (opens in a new window).
  • Email newsletters will contain health related topics such as favorite recipes, kitchen hacks, special offers and nutrition-related topics and will not be sent more than one time per month.

  • Patient Financial Agreement

    Financial Agreement: I understand that all charges are due at the time of service, and that there are no refunds on prepaid treatments. I agree to pay Nourish Your Life for all charges for nutrition therapy provided to me, or my dependent. Acceptable forms of payment include cash, check, Venmo, Visa, MasterCard, American Express, Discover, JCB, debit cards, health savings account (HSA) cards, and flexible spending account (FSA) cards. If I am a non-insured patient, I agree to pay for my visit in full at the time of service. If Nourish Your Life is a participating provider with my insurance company I understand that my co-pay, coinsurance, deductible and/or any outstanding balances are due at the time of service. Insurance Authorization and Release: I request that payment of authorized benefits, including Medicare and any other government sponsored program, private insurance, and any other health plans be made to Sandy Kipp RDN LLC, private practitioner for services provided.

    Cancellation and Rescheduling Agreement

    Nutrition counseling with a holistic approach is time intensive and requires blocks of time that average 1-2 hours per consultation. In consideration of Sandy’s time and of other patients wishing to book appointment slots, a 72 hour (not including weekends) notice of cancellation or rescheduling is required. By signing this agreement you acknowledge that you understand the above cancellation and rescheduling policy. If you choose to cancel or reschedule within 72 hours of your appointment (not including weekends) you agree to pay a $45 cancellation/rescheduling fee.

    By signing below, I acknowledge that I understand and will adhere to the Privacy, Financial, and Cancellation and Rescheduling Policies of Nourish Your Life.

  • Date: 12/09/2023

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