New Client Forms
Please download and print our new client intake forms and bring with you to your first appointment.
Parents – If your child will be seeing a dietitian at Clem&Thyme, please use the pediatric new client intake form instead of the form above.
More information on the forms (that are included in the downloadable document above) is listed below.
- Privacy Practice Acknowledgement. HIPAA policy is provided at your appointment.
- Office Policy.
- Insurance Script. This form is only necessary to complete if utilizing insurance as your form of payment.
- Authorization for Release of Information. This form is only necessary to complete if you would like your doctor to send health information to us, or would like us to fax paperwork to your doctor.
- New Patient Questionnaire. The questionnaire is lengthy, so please allow ample time to fill it out prior to your appointment. The form covers a lot of information because it helps us to be as thorough as possible and provide you with the best care to help you achieve your goals! Thank you for understanding!
If you are a Medicare (or supplemental Medicare) policy holder please download and print the Advance Beneficiary Notice of Noncoverage form. We must have this form on file to bill Medicare. This form makes you aware of your insurance rights with Medicare. Medicare will only cover nutrition therapy with diagnosis codes of diabetes and chronic kidney disease. You are limited to three hours of counseling in your first year, and two hours of counseling in subsequent years. If Medicare does not cover your appointment, you are responsible for the payment. If you are NOT a Medicare policy holder, this form does not apply to you and you do not need to complete it.