MD Offices: To refer your patients, fax the following forms to our office at: 210-735-1176.
1) Fill out and sign this REFERRAL FOR MNT 2016
2) Most recent patient Medical History and Physical Form/Office Note with Diagnosis codes
3) Most recent pertinent patient Laboratory Data
We will contact your patient within 24-hours of receiving your referral, during the work week. We will fax a progress note to your office after the initial appointment and after periodic follow-up appointments.
MD referrals are welcome but not required, unless you have Medicare insurance coverage. Your appointments with us will be educational, enjoyable and confidential. Each session will be personalized to your own individual health concerns, lifestyle, and nutritional needs. We will collaborate with you to develop short and long term goals and a personalized meal plan. Exercise and behavior changes will also be addressed.
It will be important that you are willing to make changes and follow our instructions for success. To test your readiness for change, read this article.
Since new behaviors must be repeated several times before they become a habit, regularly scheduled follow-up appointments over a six month period are encouraged to provide diet monitoring, continuing education and positive reinforcement.
On your first visit to our office you will be asked to bring:
- Food Diaries
- Listing of Medications, Vitamins and Nutritional supplements, Food Allergies or Intolerances
- Copy of Recent Blood Work, if available
- Doctor’s Referral Form or Diet Recommendations – not required
- MD’s Medical History/Office Note with Diagnosis Codes–helpful but not required. You may be able to print these off of your physician’s patient portal. Or with your approval, we can have your MD’s office fax to us.
The initial appointment will last between 1 and 1 ½ hours. During that time we will…
- Provide you with a form to sign called Informed Consent for Medical Nutrition Therapy. There is no need to print this off, unless you want a copy. This form includes a consent for treatment and allows us to release a progress note/medical information to your designated health care providers or family members.
- Complete a nutrition assessment
- Measure your body composition
- Determine your problem areas
- Develop short and long term goals
- Determine your calorie, protein and fluid needs
- Collaborate with you to develop an individualized meal plan
- Teach you the steps to follow for your particular diet success
- Provide detailed handouts
- Answer your questions
Follow-up appointments will last about 30-40 minutes. Be sure to bring your handouts and food diaries. During that time we will…
- Review your food diaries
- Discuss steps taken toward achieving your goals
- Review problem areas and set alternate goals
- Adjust the meal plan, if needed
- Answer your questions
- Praise your successes and bolster your weak areas
- Encourage you to plan positive reinforcement rewards
- Help you plan for diet relapses and other challenges
Please bring these forms with you to your first appointment.
After you have scheduled your initial appointment, it would be very helpful (not required) for you to fill out this Health and Nutrition History Form. These questions help you think through your issues and save us time during our initial session. If you prefer not to answer the questions in this format, don’t worry. We will discuss the questions in person at your session. The form works best if you fill it out in one sitting, so your computer does not go to sleep and delete your entered data. Click submit at the end of the form and it will be automatically sent to our email in box.
You will be asked to bring a 3-4 day food diary to your initial appointment. Your diary can be in any forma; paper, app or you may download and print the food diary form above to complete this step. Please include what, when, and where you eat and drink.
This notice describes how protected health information about you may be used and disclosed. This policy is in force during all of your sessions with the dietitian. You may download this form if you choose.You do not need to bring this form to your initial session.
You will be asked to sign this form if you are paying for services using your insurance coverage or if you want your nutrition counseling information released to other health care providers or family members, in order to coordinate your medical care. If you have been referred by a physician, you have already agreed to have the doctor and dietitian coordinate your care. In this case, a release will not be required. We will not release your private information to anyone, except your doctor or your parent if you are a minor, unless you agree that we do so.
If insurance does not cover your visit, payment may only be made by cash or check at the end of each appointment. Credit cards and debit cards will not be accepted. If you would like a receipt to turn in to your insurance company for reimbursement, we can provide you with a receipt.
Insurance Plans Accepted:
- HMO Blue
- BlueChoice PPO
- Blue Advantage HMO
- PAR Plan
- Commercial PPO
- Commercial POS
- Commercial EPO
Aetna POS II Plans
Medicare Plans (MD referral required)
- Traditional Medicare Part B (only covers Diabetes and Non-Dialysis Kidney Disease)
- BCBS Medicare
- Aetna Medicare Advantage
- Humana Medicare Advantage
Discount Plans through OPTUM Health Care Solutions
- Health Allies (20% discount)
- Access One Consumer Health (15%)
- Medical Resource (20%)
- Premera Blue Cross (20%)
Even though you have health insurance and may have a physician’s referral, your insurance may not cover nutrition counseling for your particular diagnosis. To check your eligibility, we will call your doctor’s office to get your diagnosis codes (ICD 10) and we will ask you for your date of birth, member ID # and group # off of your insurance card. Your payment may include a co-payment or payment toward your deductible, as specified by the insurance company. If a copay or deductible payment is required, we will inform you before the appointment. You may want to check with your insurance provider or review your own particular insurance policy for more details. Payments must be made by check or cash only. We do not accept credit or debit cards.
Discount Plans: For the OPTUM HEALTH Discount Plans, no referral is necessary. You will receive a negotiated discount off of our standard rate, and you will pay for services rendered at the time of your appointment. Be sure to bring your insurance identification card to our office at the time of your appointment. Payment must be made by cash or check only.
Medicaid: Linda is not a Medicaid provider. If Medicaid is your primary insurance, you must seek the services of a contracted Medicaid provider, in order to be covered.
Weekend Appointments: We do not take weekend appointments.