Sent
Apr 15, 2026 6:40 PM GMT
(a month ago)
From
[email protected] (Abbey Folsom MS LDN)
To
Finalized
User has finalized their signature
Finalized
User has finalized their signature
Sign Request Finalized Apr 16, 2026 4:30 PM
ABBEY FOLSOM, PLLC
[email protected] | P 850.820.3837 | F 850.203.4429
NutritionAbbey.com | PO Box 495, Tallahassee, FL 32302!
INFORMED CONSENT FOR SERVICES WITH ABBEY FOLSOM, PLLC (PAGES 1-9): I. PATIENT
CONSENT, II. GENERAL AGREEMENT, III. TELEHEALTH CONSENT, IV. PATIENT AUTHORIZATION TO USE
OR DISCLOSE PROTECTED HEALTH INFORMATION, V. PATIENT INFORMATION RELEASE CONSENT, VI.
HIPAA NOTICE OF PRIVACY PRACTICES FORM, AND VII. ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF
PRIVACY PRACTICES FORM. PLEASE LET US KNOW IF YOU HAVE QUESTIONS.
I. PATIENT INFORMED CONSENT
TO TREAT AND INFORMATION RELEASE
I, ________________________________ was provided with Informed Consent by
ABBEY FOLSOM, PLLC (DBA “Nutrition Abbey”) and voluntarily consent to provided
evaluation and nutrition advice as deemed necessary (DOB:______________).
I AUTHORIZE ABBEY FOLSOM, PLLC TO RELEASE:
Appropriate information to the following: Social Security, the Centers for Medicare and
Medicaid or intermediaries, or any other insurance compensation carrier for billing
purposes. I understand its mandatory to notify ABBEY FOLSOM, PLLC of any other party
who may be responsible for paying for the patient above.
To my insurance carrier and its agents any information concerning health care, advice,
treatment, supplies provided, or supplies needed to determine these benefits or the
benefits payable for related services.
Create and make clinical records regarding the patient and as deemed appropriate to
complete a thorough diagnosis of the patient’s needs. I understand all clinical records
are the property of ABBEY FOLSOM, PLLC and requested copies will be made available
for a reasonable fee as allowed by law.
I understand that I may receive messages from ABBEY FOLSOM, PLLC via telephone,
text, and email. Please contact to opt-out at any time. Standard text and data rates may
apply.
CELL NUMBER: EMAIL:
RESIDENTIAL ADDRESS, CITY, STATE, ZIP
PRIMARY INSURANCE
MEMBER ID:
GROUP NUMBER:
PRIMARY CARE DOCTOR:
SECONDARY INSURANCE
MEMBER ID:
GROUP NUMBER:
The above information is true and I promise to notify ABBEY FOLSOM, PLLC of any changes
in my medical history as soon as they occur.
CONSENTING SIGNATURE DATE
RELATIONSHIP TO PATIENT:
PATIENT PARENT LEGAL GUARDIAN AUTHORIZED
PERSON
HIPAA P & P Page / 11 1
V10 Updates Effective: March 23, 2026
04/15/2026
(850) 556-8232
01001547
CHP
✔
CYNEETHA STRONG, MD
RITA SMITH
04/06/1963
218 BETH CIR, TALLAHASSEE, FL 32310-9029, USA