According to the Federal Food, Drug, and Cosmetic Act, as amended, Section 201 (g) (1), the term "DRUG" is defined to mean: "Articles intended for use in the Diagnosis, Cure, Mitigation, Treatment or Prevention of disease."
A vitamin is not a drug, NEITHER is a Mineral, Trace Element, Amino Acid, Herb, or Homeopathic Remedy.
Although a Vitamin, a Mineral, Trace Element, Amino Acid, Herb or Homeopathic Remedy may have an effect on any disease process or symptoms, this does not mean that it can be misrepresented, or be classified as a drug by anyone.
Therefore, please be advised that any suggested nutritional advice or dietary advice is not intended as a primary treatment and/or therapy for any disease or particular bodily symptom.
Nutritional counseling, vitamin recommendations, nutritional advice, and the adjunctive schedule of nutrition is provided solely to upgrade the quality of foods in the client’s diet in order to supply good nutrition supporting the physiological and biomechanical processes of the human body.
I have read the above statement and understand the nature of services that I have requested Straight Nutrition to render.
Please review our HIPAA notification. Because email is not considered secure standard for transporting health information, we must notify you that at this time our symptom survey utilizes a standard email to send your health information to our practitioners at Straight Nutrition. We ARE in the process of upgrading our symptom survey to a HIPAA acceptable standard of transport, however, today, your information moves from our secure server to our practitioners via email. By agreeing to the terms of this form, you allow us to receive your health information via email and agree to our HIPAA practices as outlined below.
We are very concerned with protecting your privacy. While the law requires that you give us this disclosure, please understand that we always will, respect the privacy of your health information.
There are several circumstances in which we may have to use or disclose your health information.
We reserve the right to change our privacy practices as new regulations occur. If we make a change to our privacy practices, we will notify you in writing when you come in for nutritional consultation. Please feel free to email us at any time for a copy of any privacy notices. You may also find them in our website at the bottom of the page.
I authorize Straight Nutrition to contact me with information related to my health needs and interests. Straight Nutrition’s staff may use any phone number or email in my personal records to contact me. If contact is made by phone and I am unable to respond, a message may be left with my home answering machine or voice mail service. I may be contacted about the following:
To contact me, I authorize Straight Nutrition to use and disclose the following information:
NOTE: NO DIAGNOSIS OR NUTRITIONAL PLAN INFORMATION WILL BE USED OR DISCLOSED.
Straight Nutrition fully supports the protection of health information. Only the practitioners and office staff will use this information to contact you. While we retain the standard rights of disclosure as provided under HIPAA, this authorization allows us to access only the authorized information for contact purposes.
This authorization will remain valid for ten (10) years from the date of signature. You may revoke this authorization at any time or request to receive a copy of the protected health information to be used by writing to Straight Nutrition – 210 S. Vine St., Fallbrook, CA 92028. In this case, every effort will be made to discontinue future communications.
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