Fearless with Food, LLC Practice Policies

Below lists the current practice policies for Fearless with Food, LLC that are agreed to by all current clients. Please feel free to contact Tessa Komine if you have any questions or (if you are a current client) would like a copy of this form for your own records.

Hereafter, “I” refers to you, the client of Fearless with Food, LLC.

Nutrition Counseling

As a client of Fearless with Food, LLC (FWF), I understand that I am voluntarily engaging in nutrition services. There are possible many benefits to nutrition counseling, including healing one’s relationship with food, supporting treatment for eating disorder recovery, and improving one’s well-being. However, FWF does not guarantee the outcome or results of nutrition counseling as every client’s experience is unique. Nutrition therapy is a collaborative process and requires the participation of the client inside and outside of sessions. While your provider will collaborate with you to support you in healing your relationship with food, change can be uncomfortable and the process may bring up various unexpected emotions.

Client Rights

I have the right to end or refuse nutrition counseling as well as ask questions about my care at any time. FWF has the right to terminate services with the client at any time including but not limited to:

  • Instances of harassment, threats, or concern for the provider’s safety
  • Failure of client to provide payment of fees due
  • Client’s needs exceed the provider’s scope of practice
  • Client becomes medically unstable and/or requires a higher level of care
  • Client has not attended session or contacted dietitian for 60 days (clients may re-establish care at dietitian’s discretion)

I agree to hold FWF harmless for any and all claims, or damages, in connection with our work together and release FWF of all potential liability. I understand that I may eat food in session, go grocery shopping, or participate in mindful walks outside of the office with my dietitian as part of our work together. I hereby waive, release, and discharge any and all claims for damages or personal injury, illness, or death which I may have or which may hereafter accrue as a result of my participation in these activities.

If I decide to terminate care with FWF for any reason, I am aware that it is recommended that I meet with my dietitian for a closing session to provide any feedback I feel comfortable sharing as this can benefit future FWF clients and provides a smoother transition out of care.


As a client I understand in order to protect confidentiality, my dietitian will not make an effort to acknowledge clients in a public setting, but the client may choose to acknowledge their provider if they wish, in which case their dietitian may respond. FWF contains client information/records through the electronic medical record (EMR) Kalix, which is HIPAA compliant. FWF conducts video/virtual counseling through Doxy, which is also HIPAA compliant. All information shared between the client and FWF is confidential. I have the right to confidentiality and privacy of my Protected Health Information (PHI). However, there are some exceptions in which FWF would share this information with the appropriate individuals:

  • If I request that information be released or shared as stated and signed in a Release of Information (ROI) form
  • If your dietitian believes that you are a clear and imminent danger to self or others, the appropriate people will be contacted to prevent that occurrence.
  • If ordered by the courts
  • To other medical/healthcare practitioners for continuity of care

Please be aware that FWF shares a fax machine and printer with Asha Integrative Wellness which is accessible by providers and staff members at this clinic. Faxes that may contain confidential client information are shared with FWF electronically by the office manager at Asha Integrative Wellness and any paper copies are immediately shredded. FWF uploads any faxes received to Kalix and the electronic version is deleted. Paper mail addressed to FWF is received at Asha Integrative Wellness and stored in a locked file cabinet until it is opened and shredded by FWF.


I understand FWF may require medical records. I authorize FWF to review any medical records provided in accordance with HIPAA and under the agreement in a signed release of information. I have been provided a copy of the HIPAA Privacy Practices Notice and I understand HIPAA as outlined by the US Department of Health and Human Services.

Telehealth Services

I understand that my health care provider wishes me to engage in a telehealth services. I understand that the video conferencing technology that will be used to affect such a consultation will not be the same as a direct client/health care provider visit due to the fact that I will not be in the same room as my provider. I understand that a telehealth consultation has potential benefits including easier access to care and the convenience of meeting from a location of my choosing. I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my health care provider or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation. If I am participating in the telehealth session via phone, I understand that I should abstain from operating a vehicle during the session to minimize distractions and maintain safety (I may participate in the virtual session while in a parked car).

Fearless with Food, LLC uses the HIPPA-compliant telemedicine service, Doxy.me, for telehealth video sessions. It is simple to connect and does not require any downloads or passwords from the client. I understand that having a stable internet connection and a functioning webcam will help ensure that our video sessions run smoothly. I understand that Doxy.me is NOT an Emergency Service and in the event of an emergency, I will use a phone to call 911. Though my provider and I may be in direct, virtual contact through the Telehealth Service, Doxy.me does not provide any medical or healthcare services or advice including, but not limited to, emergency or urgent medical services. The Telehealth by Doxy.me facilitates videoconferencing and is not responsible for the delivery of any healthcare, medical advice or care. I do not assume that my provider has access to any or all of the technical information in the Telehealth by Doxy.me– or that such information is current, accurate or up-to-date. I will not rely on my health care provider to have any of this information in the Telehealth by Doxy.me. To maintain confidentiality, I will not share my telehealth appointment link with anyone unauthorized to attend the appointment.


I understand that email and text messages are not secure/confidential means of communication. If I choose to use email or text to communicate with my dietitian, there is a possibility that a third party may be able to view these messages. FWF uses the messaging app, Signal, for all texts sent to clients. Text messages between me and my dietitian are only encrypted if I am also using Signal to send my text messages. Otherwise, texts sent to and from my dietitian are not secure. I am aware of the risks of communicating with my dietitian via email or text and FWF will not provide nutrition counseling via these methods of communication. In the event of a medical or mental health emergency, I understand that I should call 911 or my local county crisis line. I understand that if I attempt to follow or contact my dietitian’s personal social media account, my dietitian will not reciprocate. I may choose to follow FWF’s professional accounts on social media, however, my dietitian will not communicate with me via social media.


I agree to keep all scheduled appointments and be on time as able. If I cannot attend a scheduled session, FWF asks that I respectfully give a minimum of 24 hours notice to cancel and/or reschedule. I understand if I miss an appointment or cancel with less than 24 hours of notice, then I will be charged a $65 fee (prorated to $35 for half sessions). FWF may waive this fee at the dietitian’s discretion in the event of medical or family emergencies, illness or other extenuating circumstances. If I have OHP/Medicaid as insurance, this fee will not apply. Instead, in the event of 2 consecutive late cancellations or no-shows, there will be a 30 day holding period before you may return to services. At this time, the provider will re-evaluate whether scheduling appointments one at a time or recurring sessions will be more appropriate. This can also be waived on a case-by-case basis if discussed with your dietitian. These policies are in place to recoup some of the cost of sessions as I am not able to bill insurance for these missed appointments and to allow for spots to be filled by those who might be on my waitlist. In the event of a no-show or late cancellation, if contact is not made between myself and FWF within 3 business days, I understand that my dietitian may need to cancel any upcoming scheduled appointments until I confirm my attendance. I understand that FWF may change business operating hours, which may impact the scheduling of future appointments. I understand that my dietitian may take several cumulative weeks of vacation time per calendar year. I understand that my provider will make a best effort to call or email me in in the event of an emergency or illness and is unable to attend our scheduled appointment.

Fees & Insurance

Nutrition sessions are $150 for initial appointments (53-60 minutes), $130 for 53 minute follow-up appointments and $65 for 25 minute follow-up appointments, regardless of whether they are conducted in the office or via telehealth. If a claim submitted to insurance is denied for any reason, I understand that I am responsible for the full cost of the session.

FWF is an in-network provider with several insurance companies, although this does not guarantee coverage of nutrition services. FWF will submit insurance claims electronically for nutrition sessions as a courtesy. I authorize the release of my medical information necessary to process the claim if requested by my insurance. I understand that I am responsible for determining my insurance coverage (including copayments and whether payments must be made towards my deductible) for nutrition sessions. I understand that I am fully responsible for payment of services whether insurance covers nutrition visits or not.

If FWF is billing for sessions as an out-of-network provider, payment for the full cost of the session is due at time of service. Upon request, FWF can provide a superbill at no cost to the client for them to submit to their insurance or Health Savings Account (HSA) for reimbursement Invoices may also be provided at no cost upon request. I understand that FWF is not responsible for insurance reimbursing me.

By signing this statement, I am authorizing Tessa Komine/Fearless with Food, LLC to complete any necessary insurance claim forms on your behalf. I also authorize the release of any medical or other information which may be needed in order to process my claims. My signature will be kept on file and shall be referred to when insurance claim forms are submitted for healthcare services I have received. I understand that insurance companies require a diagnosis in order to process claims. I understand that it is outside my dietitian’s scope of practice to diagnosis me with a medical or mental health condition, so a general nutrition diagnosis will be used unless proof of a diagnosis (such as an eating disorder) is provided by one of my other providers (e.g. doctor, therapist, prescriber, etc.).

All clients (unless they have OHP insurance) are requested to keep a credit/debit card on file per the Payment Authorization Form. This information will be stored in the HIPAA-complaint electronic health record (Kalix) and any paper copies with this information will be shredded. This card will be charged for any late fees, copayments or coinsurance payments, costs not covered by insurance, and self-pay rates. The client is responsible for timely payments for services and failure to pay balance in full may result in termination of services.

Telephone calls that are 10 minutes or less are considered complementary. For phone calls that last 15 minutes or longer, a rate of $35 per 15 minutes will apply.


HIPAA Notice of Privacy Practices

This notice describes how protected health information about you may be used and disclosed and how you can get access to this information. please review this carefully.

Our Pledge Regarding Protected Health Information We understand that protected health information about you and your health is personal. We are committed to protecting health information about you. This Notice applies to all records of your care generated by , whether made by personnel or your dietitian.

This Notice will tell you about the ways in which we may use or disclose protected health information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of protected health information. Federal law requires us to:

  • Make sure that protected health information that identifies you is kept private;
  • Notify you about how we protect protected health information about you;
  • Explain how, when, and why we use and disclose protected health information; and
  • Follow the terms of the Notice that is currently in effect.

We are required to follow the procedures in this Notice. We reserve the right to change the terms of this Notice and to make new Notice provisions effective for all protected health information that we maintain by:

  • Posting the revised Notice in our office;
  • Making copies of the revised Notice available upon request; and
  • Posting the revised Notice on our Website.

How We May Use and Disclose Protected Health Information About You

The following categories describe different ways that we may use and disclose protected health information without your written authorization.

For Treatment. We may use protected health information about you to provide you with, coordinate, or manage your medical treatment or services. We may disclose protected health information about you to doctors, nurses, technicians, medical students, or other Fearless with Food, LLC personnel, including persons outside of our office who are involved in your medical care.

Fearless with Food, LLC staff may also share protected health information about you in order to coordinate your care for such reasons as prescriptions, lab work, and x-rays.

For Health Care Operations. We may use and disclose protected health information about you for Fearless with Food, LLC health care operations, such as our quality assessment and improvement activities, case management, coordination of care, business planning, customer service, and other activities. These uses and disclosures are necessary to run the facility, reduce health care costs, and make sure that all of our clients receive quality care. For example, we use the HIPAA compliant web-based practice management and electronic medical record (EMR) Kalix for appointment scheduling, electronic record keeping and filing, electronic paperwork and coordination of care. Your protected health information is recorded, stored and transmitted in Kalix in an encrypted state. We may also combine protected health information about many Fearless with Food, LLC’s clients to decide what additional services Fearless with Food, LLC should offer, what services are not needed, and whether certain treatments are effective. We review our treatment and services or to evaluate the performance of the practitioner who is providing your services. We may also disclose information to doctors, nurses, technicians, medical students, and other Fearless with Food, LLC personnel for review and learning purposes.

Subject to applicable state law, the law allows or requires us to use or disclose your health information without your authorization in some limited situations for purposes beyond treatment, payment, and operations.

As Required by Law. We will disclose protected health information about you when required to do so by federal, state, or local law.

Research. We may disclose your protected health information to researchers when their research has been approved by an institutional review board or privacy board that has reviewed the research proposal and established protocols to ensure the privacy of your information. We may permit researchers to review records to help identify patients who may be included in their research projects or for similar purposes as long as the researchers do not remove or take a copy of any health information.

To Avert a Serious Threat to Health or Safety. We may use and disclose protected health information when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. We may also disclose protected health information about you to a government authority if we reasonably believe that you are a victim of abuse, neglect, or domestic violence. We will only disclose this type of information to the extent required by law, and we will only disclose it if (a) you agree to the disclosure, or (b) the disclosure is allowed by law and we believe it is necessary to prevent or lessen a serious and imminent threat to you or another person.

Judicial and Administrative Proceedings. We may disclose your protected health information in response to a court or administrative order. We may also disclose your protected health information in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made, either by us or the requesting party, to tell you about the request or to obtain an order protecting the information requested.

Business Associates. We may disclose information to business associates who perform services on our behalf including our EMR and practice management solution Kalix and clearinghouse Office Ally. However, we require that these associates appropriately safeguard your information. Our business associates are obligated to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.

Public Health. As required by law, we may disclose your protected health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.

Health Oversight Activities. We may disclose protected health information to a health oversight agency for activities authorized by law. These activities include audits, investigations, and inspections, as necessary for licensure and for the government to monitor the health care system, government programs, and compliance with civil rights laws.

Law Enforcement. We may release protected health information as required by law, or in response to an order or warrant of a court, a subpoena, or an administrative request. We may also disclose protected health information in response to a request related to identification or location of an individual, a victim of crime, a decedent, or a crime on the premises.

Organ and Tissue Donation. If you are an organ donor, we may release protected health information to an organ donation bank or to organizations that handle organ procurement or organ, eye, or tissue transplantation, as necessary to facilitate organ or tissue donation and transplantation.

Special Government Functions. If you are a member of the armed forces, we may release protected health information about you if it relates to military and veterans activities. We may also release your protected health information for national security and intelligence purposes, protective services for the President, and medical suitability or determinations made by the Department of State.

Coroners, Medical Examiners, and Funeral Directors. We may release protected health information to a coroner or medical examiner. This release may be necessary, for example, to identify a deceased person or determine the cause of death. We may also disclose protected health information to funeral directors, consistent with applicable laws, to enable
them to carry out their duties.

Correctional Institutions and Other Law Enforcement Custodial Situations. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release protected health information about you to the correctional institution or law enforcement official as necessary for your or another person’s health and safety.

Worker’s Compensation. We may disclose protected health information as necessary to comply with laws relating to worker’s compensation or other similar programs established by law.

Food and Drug Administration (FDA). We may disclose to the FDA, or persons under the jurisdiction of the FDA, protected health information relative to adverse events with respect to drugs, foods, supplements, products, and product defects, or post marketing surveillance information to enable product recalls, repairs, or replacement.

Fundraising and/or Marketing Communications. We may contact you about fundraising activities or to market health-related services or benefits. You have the right to opt-out of this type of communication by contacting us. Fearless with Food, LLC will not sell your information to any third party.

Appointment Reminders, Treatment Alternatives, and Health-Related Benefits and Services. We may use and disclose protected health information to contact you (by email, telephone, voice message and/or text (SMS) message) as a reminder (including automated reminders sent via Kalix EMR and Practice Management Solution) that you have an appointment for treatment or medical care. We may use and disclose protected health information to tell you about or recommend possible treatment options, treatment alternatives, or health-related benefits or services that may be of interest to you.

For Work-Related Injuries or Illnesses or Workplace Medical Surveillance. We may disclose health care information where your employer has a duty under state or federal law, to keep records or act on such information.

Incidental Disclosures may occur as a by-product of permitted uses and disclosures of your health care information. These incidental disclosures are permitted if we have applied reasonable safeguards to protect the confidentiality of your health care information.

Electronic Medical Record

To promote quality care, Fearless with Food, LLC operates an electronic medical record (EMR) Kalix. Fearless with Food, LLC providers and some providers unaffiliated with Fearless with Food, LLC may have access to the EMR. Your medical record may be comprised of information in the EMR as well as in a paper record. Fearless with Food, LLC is legally obligated to notify any individual whose protected health information is affected by a security breach.

You Can Object to Certain Uses and Disclosures

Unless you object, or request that only a limited amount or type of information be shared, we may use or disclose protected health information about you in the following circumstances: We may share with a family member, relative, friend or other person identified by you protected health information that is directly relevant to that person’s involvement in your care or payment for your care. We may also share information to notify these individuals of your location, general condition, or death. We may share protected health information with a public or private agency (such as the American Red Cross) for disaster relief purposes. Even if you object, we may still share this information if necessary under emergency circumstances. If you would like to object to use and disclosure of protected health information in these circumstances, please call us.

Your Rights Regarding Protected Health Information About You

You have the following rights regarding protected health information that we maintain about you:

Right to Inspect and Copy. You have the right to inspect and copy protected health information that may be used to
make decisions about your care or payment for your care, including protected health information stored electronically, you can request that we provide access in an electronic format that is readily producible, or in a format agreed to by us.

To inspect and copy protected health information that may be used to make decisions about you, you must submit your request in writing to . If you request a copy of the information, we may charge a fee for the costs of copying, mailing, or supplies associated with your request. We may not charge you a fee if you need the information for a claim for benefits under the Social Security Act or any other state or federal needs-based benefit program. We will respond to your request no later than 30 days after we receive it. There are certain situations in which we are not required to comply with your request. In these circumstances, we will respond to you in writing, stating why we will not grant your request and describe any rights you may have to request a review of our denial.

Right to Amend. 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, your request must be made in writing and submitted to . In addition, you must provide a reason that supports your request. We will act on your request for an amendment no later than 60 days after we receive it. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In these circumstances, we will provide a written denial stating why we will not grant your request. In addition, we may deny your request if you ask us to amend information that:

  • Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
  • Is not part of the protected health information kept by Fearless with Food, LLC;
  • Is not part of the information that you would be permitted to inspect and copy; or
  • We believe is accurate and complete.

Right to an Accounting of Disclosures. You have the right to request an “accounting of disclosures.” This is a list of the disclosures we made of protected health information about you.

To request this list of disclosures, you must submit your request in writing to . You may ask for disclosures made within the six years before your request. The first list you request within a 12-month period will be free. For additional lists in that 12-month period, we may charge you for the costs of providing the list. We are required to provide a list of all disclosures except the following:

Disclosures made for your treatment;
– Those used for billing and collection of payment for your treatment; – Those related to health care operations; – Those made to you or requested by you, or those that you authorized; – Those that occurred as a byproduct of permitted use and disclosures; – Those used for national security or intelligence purposes, or provided to correctional institutions or law enforcement regarding inmates; – Those that were a part of a limited data set of information that does not contain information identifying you.

Right to Request Restrictions. You have the right to request a restriction or limitation on the protected health information we use or disclose about you for treatment, payment, or health care operations, or to persons involved in your care.

We are not required to agree to your request. If we do agree, we 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 required by law. To request restrictions, you must make your request in writing to .

Right to Request Confidential 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 we only contact you at work or by mail. To request confidential communications, you must make your request in writing to . We will accommodate all
reasonable requests.

Right to a Paper Copy of This Notice. You have the right to a paper copy of this Notice at any time even if you have agreed to receive it electronically. We encourage you to read and ask questions about this Notice.

Right to Receive Notice of Breach. You have a right to be notified upon a breach of any of your unsecured protected health information.

Rights for Out-of-Pocket Payments. If you paid out of pocket in full for a specific item or service, you have a right to ask that your protected health information with respect to that item or service not be disclosed to a health plan for purposes of payment or health care operations. We are required to agree to your request unless the disclosure is otherwise required by law.

Types of Uses and Disclosures Requiring an Authorization

Most uses and disclosures of psychotherapy notes require us to obtain an authorization from you. In addition, in most instances, we cannot use or disclose your protected health information for marketing purposes or sell your protected health information without your written authorization. Finally, any other use or disclosure not described in this Notice will be made only with your authorization. Any time you provide us with a written authorization, you may revoke it any time in writing, to the extent that we have not already taken action in reliance on your previous authorization.

Other Uses and Disclosures

We will obtain your written authorization before using or disclosing your protected health information for purposes other than those described in this Notice (or as otherwise permitted or required by law). You may revoke this authorization in writing at any time. Upon receipt of the written revocation, we will stop using or disclosing your information, except to the extent that we have already taken action in reliance on the authorization.

You May File a Complaint About Our Privacy Practices

If you believe your privacy rights have been violated, you may file a complaint with or file a written complaint with the Secretary of the Department of Health and Human Services. A complaint to the Secretary should be filed within 180 days of the occurrence or action that is the subject of the complaint. If you file a complaint, we will not take any action against you or change our treatment of you in any way.

Changes to This Notice

We reserve the right to change this Notice and make the new Notice apply to health information we already have, as well as any information we receive in the future. We will post a copy of our current Notice in our office. The notice will have the effective date clearly marked at the top of the first page.