NUTRITION COUNSELLING

Insurance plans accepted: Blue Cross Blue Shield, Harvard Pilgrim Healthcare, and Mass General Brigham health plan (previously called Allways). Services may also be eligible for reimbursement through other health insurance plans with out-of-network benefits. Contact me for my current self-pay rates.

Office hours are on generally on Mondays and Wednesdays, and are exclusively virtual via a secure telehealth portal.

The cancellation policy is 24 hours from the time of our appointment. Cancellations made within 24 hours of your scheduled appointment will result in being charged the full fee (cancellation fees are not covered by insurance).

You have the right to receive a “Good Faith Estimate” explaining how much your health care will cost.

• Under the law, health care providers need to give patients who don’t have certain types of health care coverage or who are not using certain types of health care coverage an estimate of their bill for health care items and services before those items or services are provided.

• You have the right to receive a Good Faith Estimate for the total expected cost of any health care items or services upon request or when scheduling such items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.

• If you schedule a health care item or service at least 3 business days in advance, make sure your health care provider or facility gives you a Good Faith Estimate in writing within 1 business day after scheduling. If you schedule a health care item or service at least 10 business days in advance, make sure your health care provider or facility gives you a Good Faith Estimate in writing within 3 business days after scheduling. You can also ask any health care provider or facility for a Good Faith Estimate before you schedule an item or service. If you do, make sure the health care provider or facility gives you a Good Faith Estimate in writing within 3 business days after you ask.

• If you receive a bill that is at least $400 more for any provider or facility than your Good Faith Estimate from that provider or facility, you can dispute the bill. Make sure to save a copy or picture of your Good Faith Estimate and the bill.

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises/consumers, email FederalPPDRQuestions@cms.hhs.gov, or call 1-800-985-3059.

PRIVACY ACT STATEMENT:

CMS is authorized to collect the information on this form and any supporting documentation under section 2799B-7 of the Public Health Service Act, as added by section 112 of the No Surprises Act, title I of Division BB of the Consolidated Appropriations Act, 2021 (Pub. L. 116-260). We need the information on the form to process your request to initiate a payment dispute, verify the eligibility of your dispute for the PPDR process, and to determine whether any conflict of interest exists with the independent dispute resolution entity selected to decide your dispute. The information may also be used to: (1) support a decision on your dispute; (2) support the ongoing operation and oversight of the PPDR program; (3) evaluate selected IDR entity’s compliance with program rules. Providing the requested information is voluntary. But failing to provide it may delay or prevent processing of your dispute, or it could cause your dispute to be decided in favor of the provider or facility.

© 2023 Sandra Klemmer

HIPAA (Health Insurance Portability and Accountability Act of 1996): Notice of Privacy Practices

This notice describes how medical information about you may be used and disclosed and how you can obtain access to that information. It pertains to the private nutrition practice of Sandra Klemmer (referred to as “I,” “my practice,” “the practice,” and “this practice”)

Please review this notice carefully. If you have questions, please contact Sandra Klemmer at 617.697.3185 or Sandra.K.Klemmer@gmail.com.

Policy statement

I understand that protected health information about you and your health is personal. I am committed to protecting health information about you.

The Private nutrition practice of Ms. Klemmer is committed to maintaining the privacy of your protected health information (PHI), which includes electronic protected health information, as well as information about your condition and the care and treatment you receive from this practice and other health care providers. This notice details the use and disclosure of your PHI to third parties for purposes of your care, payment for your care, health care operations of the practice, and other purposes permitted or required by law. This notice also details your rights regarding your PHI.

1) Use or disclosure of PHI

This practice may use and/or disclose your PHI for purposes related to your care, payment for your care, and health care operations of the practice. The following are examples of the types of uses and/or disclosures of your PHI that may occur and are not meant to include all possible types of use and/or disclosure:

Your Care and Treatment

In order to provide, coordinate or manage your care, this practice may provide your PHI to those health care professionals directly involved in your care, so that they may understand your condition and needs, and provide advice or treatment. I may disclose protected health information about you to doctors, nurses, technicians, medical students, or other personnel involved your care.

This includes communication with your primary physician and electronic interactions with you (e.g. e-mail), as well as other individuals involved in your care pending your authorization for information release. I may also share protected health information about you in order to coordinate the different things you need, such as prescriptions, lab work and x-rays.

Payment

In order to get paid for some or all of the health care provided by Sandra Klemmer, my practice may provide your PHI to appropriate third-party payers, pursuant to their billing and payment requirements, so that the treatment and services you receive from Ms. Klemmer may be billed to and payment may be collected from you, an insurance company or a third party. For example, I may need to give your health plan information about the nutrition services you received so that your health plan can determine whether or not it will pay for the expense. I may also tell your health plan about the nutrition services you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.

Health care operations

In order for the practice to operate, in accordance with applicable law and insurance requirements, and in order for my practice to provide quality and efficient care, I may need to compile, use, and/or disclose your PHI. For example, I may use and disclose protected health information about you for health care operations, such as quality assessment and improvement activities, case management, coordination of care, business planning, or other operational activities. These uses and disclosures are necessary to run my practice and help make sure that patients receive quality care.

Authorization not required

• As required by law, I will disclose protected health information about you when required to do so by federal, state or local law. I may use and/or disclose your PHI without a written authorization from you in the following instances:

• De-identified information: Your PHI is altered so that it does not identify you. Even without your name, it cannot identify you.

• To a relevant business associate: My practice will obtain satisfactory written assurance, in accordance with applicable law, that business associates will appropriately safeguard your PHI. A business associate is someone who the practice contracts with to provide a service necessary for your treatment or payment for your treatment and health care operations (e.g. billing service or transcription service).

• To a personal representative: This person (“representative”), under applicable law, has the authority to represent you in making decisions related to your health care.

• For public health activities: These activities include information collected by a public health authority, as authorized by law, to prevent or control disease, injury, or disability. This includes reports of child abuse or neglect.

• To the US Food and Drug Administration (FDA): The FDA may require this information in the reporting of adverse events, product defects or problems, or biological product deviations; for tracking of products; for enabling of product recalls, repairs, or replacements; or when conducting post-marketing surveillance.

• Abuse, neglect, or domestic violence: If law requires, I may need to make such a disclosure to a government authority. If I am authorized by law to make such a disclosure, I will do so if it believes that the disclosure is necessary to prevent serious harm or if this practice believes that you are the victim of abuse, neglect, or domestic violence. Any such disclosure is made in accordance with the requirements of law, which also may involve notice to you of the disclosure.

• Health oversight activities: These activities are required by law, and involve government agencies with oversight into activities that are related to the health care system, government benefit programs, government regulatory programs, and civil rights law. These activities include criminal investigations, audits, disciplinary actions, or general oversight activities related to the community’s health care system.

• Judicial and administrative proceedings: My practice may need to disclose your PHI in response to a court order or a lawfully issued subpoena.

• Law enforcement purposes: In certain instances, it may become necessary to disclose your PHI to a law enforcement official for law enforcement purposes, including:

• Compliance with a legal process (ie, subpoena) or as required by law

• Information for identification and location purposes (eg, suspect or missing person)

• Information regarding a person who is or is a suspected crime victim

• In situations where the death of an individual may have resulted from criminal conduct

• In the event of a crime occurring on the premises of the practice

• An occurrence of a medical emergency not on the practice’s premises, where it appears that a crime has occurred

• Coroner or medical examiner: The practice may disclose your PHI to a coroner or medical examiner for the purpose of identifying you or determining your cause of death, or to a funeral director as permitted by law and as necessary to carry out related duties.

• Organ, eye, or tissue donation: If you are an organ donor, my practice may disclose your PHI to the entity to whom you have agreed to donate your organs.

• Research: If my practice is involved in research activities, I may use your PHI, but such use is subject to numerous governmental requirements intended to protect the privacy of your PHI, such as approval of the research by an institutional review board and a requirement that protocols are followed.

• A threat to health or safety: My practice may disclose your PHI if it believes that such disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. The disclosure is to an individual who is reasonably able to prevent or lessen the threat.

• Specialized government functions: When the appropriate conditions apply, my practice may use the PHI of individuals who are armed forces personnel for activities deemed necessary by appropriate military command authorities, for the purpose of a determination by the US Dept of Veteran Affairs of eligibility for benefits, or to a foreign military authority if the individual is a member of that foreign military service. This practice also may disclose a PHI to authorized federal officials for conducting national security and intelligence activities, including the provision of protective services to the President or others legally authorized.

• Inmates: I may disclose your PHI to a correctional institution or a law enforcement official, if you are an inmate of that correctional facility and your PHI is necessary to provide care and treatment to you, or if it is necessary for the health and safety of other individuals or inmates.

• Workers’ Compensation: If you are involved in a Workers’ Compensation claim, Workers’ Compensation may require the practice to disclose your PHI to an individual or entity that is part of the Workers’ Compensation system.

• Disaster relief efforts: The practice may use or disclose your PHI to a public or private entity authorized to assist in disaster relief efforts.

• Required by law: If required by law, I will use or disclose your PHI in compliance with the law, limited to the requirements of the law.

Authorization

Uses and/or disclosures other than those previously described are made only with your written authorization, which you may revoke at any time.

Appointment reminder

My practice may contact you to provide appointment reminders. The reminder may occur in the form of a letter or postcard, by e-mail, or text message/telephone (and if you are not available, the practice will leave a message for you). I will try to minimize the amount of information contained in the reminder.

Treatment alternative/benefit

The practice may, from time to time, contact you about treatment alternatives or other health benefits/services that may interest you.

Family/friends

Ms. Klemmer may disclose -- to your family member, other relative, a close personal friend, or any other person identified by you -- your PHI directly relevant to such person’s involvement with your care or the payment for your care. The practice also may use or disclose your PHI to notify or assist in notifying (including identifying or locating) a family member, a personal representative, or another person responsible for your care of your location, general condition, or death.

However, in both cases, the following conditions will apply:

• I may use or disclose your PHI if you agree, or if my practice provides you with an opportunity to object and you do not object, or if the practice can reasonably infer from the circumstances, based on the exercise of its judgment, that you do not object to the use or disclosure.

• If you are not present, I will, in the exercise of its judgment, determine whether the use or disclosure is in your best interests and, if so, disclose only the PHI that is directly relevant to the person’s involvement with your care.

2) Your Rights

You have the right to:

• Revoke any authorization, in writing, at any time. To request a revocation, you must submit a written request to Ms. Sandra Klemmer.

• Request restrictions on certain use and/or disclosure of your PHI as provided by law. You have the right to request a restriction or limitation on the protected health information I use or disclose about you for treatment, payment or health care operations or to persons involved in your care. However, Ms. Klemmer is not obligated to agree to any requested restrictions. If I do agree, I will comply with your request unless the information is needed to provide you emergency treatment, the disclosure is to the Secretary of the Department of Health and Human Services, or the disclosure is for one of the purposes described on pages 2-3. To request restrictions, you must submit a written request to Ms. Klemmer. In your written request, you must inform the practice of what information you want to limit, whether you want to limit the practice’s use or disclosure, or both, and to whom you want the limits to apply.

• Right to request confidential or alternative communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that I only contact you at work or by mail. To request confidential communications, you must make your request in writing to Sandra Klemmer. I will accommodate all reasonable requests.

• Inspect and copy your PHI as provided by law. To inspect and copy your PHI, you must submit a written request to Ms. Klemmer. In certain situations that are defined by law, my practice may deny your request, but you will have the right to have the denial reviewed. The practice can charge you a fee for the cost of copying, mailing, or other supplies associated with your request.

• Amend your PHI as provided by law. If you feel that protected health information we have about you is incorrect or incomplete, you may ask us to amend or supplement the information. To request an amendment, you must submit a written request to Ms. Klemmer. You must provide a reason that supports your request. My practice may deny your request if it is not in writing, if you do not provide a reason and support of your request, if the information that needs amended was not created by the practice (unless the individual or entity that created the information is no longer available), if the information is not part of your PHI maintained by my practice, if the information is not part of the information you would have permission to inspect and copy, and/or if the information is accurate and complete. If you disagree with the practice’s denial, you have the right to submit a written statement of disagreement.

• Receive an accounting of disclosures of your PHI as provided by law. This refers to a list of the disclosures I made of protected health information about you. To request an accounting, you must submit a written request to Ms. Klemmer. The request must state a time period [not longer than 6 years, and cannot including disclosures made before April 14, 2004, which precedes the establishment of this practice]. The request should indicate in what form you want to receive the list, such as a paper or electronic copy. The first list you request within a 12-month period is free, but my practice may charge you for the cost of providing additional lists in that same 12-month period. My practice will notify you of the costs involved, and you can decide to withdraw or modify your request before any costs are incurred.

• Receive a paper copy of this Notice of Privacy Practices from the practice at any time by contacting Sandra Klemmer.

• Complain to the practice or to the Office of the Secretary, US Dept of Health and Human Services, Office for Civil Rights if you believe your privacy rights have been violated. You may contact a regional office of the Office for Civil Rights (locations available at www.hhs.gov/ocr/regmail.html). If you file a complaint, we will not take any action against you or change our treatment of you in any way.

• Obtain more information or to have your questions about your rights answered. Contact Sandra Klemmer at 617-697-3185 or Sandra.k.klemmer@gmail.com

3) Practice’s Requirements

The practice of Sandra Klemmer:

• Is required by law to maintain the privacy of your PHI and to provide you with this Notice of Privacy Practices of my practice’s legal duties and privacy practices with respect to your PHI.

• Is required to abide by the terms of this Notice of Privacy Practices.

• Reserves the right to change the terms of this Notice of Privacy Practices and to make the new Notice of Privacy Practices provisions effective for your entire PHI that it maintains.

• Will not retaliate against you for making a complaint.

• Must make a good faith effort to obtain from you an acknowledgement of receipt of this notice.

• Will post this Notice of Privacy Practices on the practice’s Web site, if it maintains a Web site.

• Will provide this Notice of Privacy Practices to you by e-mail, if you so request. However, you also have the right to obtain a paper copy of this Notice of Privacy Practices.

Effective date: This notice is in effect as of November 1st, 2012 upon the establishment of this practice (reviewed October 31, 2023).