SCHEDULING AN APPOINTMENT & FORMS

For your convenience, here are commonly used forms in PDF format.

Referral Form (.pdf, 103kb) – Required for medical nutrition therapy.

Patient Registration Form (.pdf, 135kb) – Please download, complete, and bring to your first appointment.

Food Record Form (.pdf, 97kb) – Please download, complete, and bring to your first appointment.

What to Bring

For medical nutrition therapy, a written referral from your doctor or nurse practitioner is required. Please bring the referral form to your appointment, if it has not already been mailed or faxed to Nutrition Clinic of Northern California. By law, you must have a written referral to receive medical nutrition therapy.

Completed patient registration form.

A copy of recent lab results. Or ask your doctor to fax lab results to us.

A three-day food record, a written record of everything you eat and drink for three days.

Insurance

Our services are covered by many major health insurance providers. Please contact your insurance company to determine if nutrition counseling services will be covered. If you do not have these benefits, talk with your employer’s benefits department to have medical nutrition therapy covered as a benefit.

You may be required to self-pay for your appointment if your insurance does not cover our services. If your insurance does cover our services, please note that we will provide a printed “superbill” that is accepted for reimbursement by many insurance carriers.

Referring Physicians

To refer a patient to Nutrition Clinic of Northern California, please follow the steps below.

Step 1 – Referral Information

Please download a referral form from above, complete and email back to us. Please be sure to include ICD-9 codes for diagnoses you wish the dietitian to address, as well as pertinent medical records, including recent lab results.

Step 2 – Insurance Check

Our services are covered by many major health insurance providers. Patients should be informed that they may be required to self-pay if their insurance does not authorize nutrition counseling. The patients should be instructed to contact his or her insurance company to determine whether nutrition counseling is a covered benefit. Authorization should be confirmed before an appointment is scheduled at Nutrition Clinic of Northern California.

Step 3 – Scheduling

Once you have sent the referral to Nutrition Clinic of Northern California and the insurance coverage is determined, please ask the patient to email us to schedule a nutrition counseling appointment.