Please provide contact information for any person(s) with whom you choose to have us communicate as part of your treatment team: physician, specialist, therapist, previous dietitian, treatment center, school/university personnel, and/or family member.
A coordination letter can be sent at your request to ensure a greater understanding of your nutritional interventions and better coordination of patient care. Issuing a coordination letter will be billed at $50 for each letter issued.
Coordination letter payments can be sent through this HIPAA-protected link.
If you do not want us to share information or gain access to information, please indicate this in the first question of this form.