Seek Medical Nutrition Therapy at DietGenics

Acknowledgment of Receipt of Notice of Privacy Practices & Authorization for Release of Confidential Information. Read the Notice of Privacy Practice. (Health Insurance Portability and Accountability Act- HIPAA) in a new browser tab: Click Here
The Patient or Parent of a minor have received a copy of Dietgenics, Nutrition Consulting, LLC/Araceli Vázquez, Notice of PrivacyPractice. (Health Insurance Portability and Accountability Act- HIPAA). If I do not choose an expiration date, I understand that my agreement will not expire.

I authorize Dietgenics, Nutrition Consulting, LLC to release my nutritional counseling and related information either by telephone, electronically, fax or in writing to the following person(s): Example: Dr or Dr Office. Please indicate in the form.

I am also aware that if I do not call to cancel my appointment within 24 hours, at 972-822-0791 or 972-664-0846 a “No Call/ No Show” fee of $25.00 will be charged to me and I am responsible for the payment. This office will make good efforts to call or text you to confirm your appointment. However, it remains your responsibility to call as stated above, if any changes.

INSURED’S OR AUTHORIZED PERSON’S SIGNATURE(Parent or Legal Guradian if minor) I authorize direct payment of medical nutrition therapy benefits to Dietgenics Nutrition Consulting, LLC/Araceli Vazquez, MS, RD, LD for services rendered; and authorize the release of any medical or other information necessary to process this claim and for collection efforts of past due balances. I certify that the above information given by me is correct. I UNDERSTAND THAT I AM FULLY FINANCIALLY RESPONSIBLE FOR ANY BALANCE NOT COVERED BY MY INSURANCE and ALL FEES GENERATED BY COLLECTION AGENCY.