1. I am engaging Medical Nutrition Therapy (MNT) services at Sinnergy Wellness Group, a private-pay dietitian practice. Services may include nutrition assessment, individualized counseling, meal planning, behavioral nutrition interventions, and evidence-based education regarding food, eating, and body wellness.
2. I understand my provider is a Registered Dietitian Nutritionist (RDN/LDN) — not a physician — and does not diagnose or treat medical conditions. Nutrition counseling is complementary to, not a substitute for, physician-directed medical care. All diagnoses and prescriptions are the sole responsibility of my licensed medical or psychiatric provider.
3. I understand that nutrition assessment findings are used to develop a personalized nutrition plan and to monitor my progress. Assessment is not intended for disease diagnosis.
4. My provider maintains secure clinical records in a HIPAA-compliant electronic health record (Healthie). Records include session notes, treatment plans, assessments, and care coordination documents.
5. All health information is strictly confidential under HIPAA and applicable Arizona state law. Information will not be shared without a signed Release of Information, except as required by law.
6. I acknowledge receipt and understanding of the Sinnergy Wellness Group Notice of Privacy Practices.
7. Sinnergy Wellness Group is a private-pay practice. We do not bill insurance companies under any circumstances. Payment is due in full at the time of service. A valid credit card on file is mandatory.
8. As required by the No Surprises Act (45 CFR § 149.610), I have the right to receive a Good Faith Estimate (GFE) of expected charges prior to services. I will not be billed more than $400 above my GFE without prior written notice and consent.
9. I agree to hold Sinnergy Wellness Group and its providers harmless for any claims arising from my participation in nutrition therapy, except in cases of gross negligence or willful misconduct.
10. Either party may terminate services at any time. A formal closing session is strongly recommended for continuity of care and clinical closure.

I certify that all information I provide is truthful and complete. I agree to the terms of nutrition therapy as described above.

THIS NOTICE DESCRIBES HOW YOUR HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU MAY ACCESS THIS INFORMATION. PLEASE READ CAREFULLY.

We are legally required by HIPAA (45 CFR Parts 160 and 164) to maintain the privacy of your protected health information (PHI), provide you this Notice, and follow its current terms. We may update this Notice; the current version is always available at our office and website.

Treatment: With your signed Release of Information, we may communicate with your physician, therapist, psychiatrist, or other authorized providers to coordinate your care.

Operations: PHI may be used internally for quality improvement, supervision, and practice management. It will not be shared outside the practice without your authorization.

Required by law: We are legally required to disclose PHI in cases of suspected child or vulnerable adult abuse or neglect, imminent danger to self or others, court orders, or public health reporting requirements.

All other disclosures — including to family members, employers, schools, and other healthcare providers — require your written Release of Information. You may revoke any authorization in writing at any time.

• Access: Request a copy of your records (within 30 days of request).
• Amendment: Request corrections to inaccurate or incomplete records.
• Accounting of disclosures: Request a list of non-treatment disclosures from the past 6 years.
• Restriction: Request limits on how your PHI is used (we may or may not be required to agree).
• Confidential communications: Request contact via a specific address, phone, or email.
• Paper copy of this Notice: Available upon request at any time.

To exercise any of these rights, contact: [email protected] · (480) 382-6109 · 8700 E. Vista Bonita Suite 236, Scottsdale, AZ 85255

Complaints may also be filed with the U.S. Department of Health & Human Services, Office for Civil Rights.

Appointments may be scheduled by calling/texting (480) 382-6109 or through your Healthie client portal. Recurring appointments must be arranged by phone. Office hours: Tuesdays, Thursdays, and Saturdays. All other inquiries to [email protected].

Superbills contain CPT procedure codes and ICD-10 diagnostic codes selected by Kristine Sinner within the scope of Medical Nutrition Therapy. All psychiatric, medical, and other diagnostic codes must be provided by your authorized diagnosing provider (psychiatrist, physician, or licensed diagnostician) and are not assigned by this practice. Sinnergy Wellness Group will provide supporting documentation for medical necessity upon request from your insurer.

Superbills are issued by the 5th business day of each month for the prior month's sessions. ICD-10 codes must be on file from your diagnosing provider before a superbill can be generated. Contact [email protected] to request a superbill.

* The Custom Meal Plan Add-On provides a personalized, rotating weekly meal plan delivered monthly via your Healthie portal. This is an optional service added to any active nutrition therapy plan. Month-to-month — cancel anytime with 30 days written notice to [email protected].

*Discount packages and sliding-scale arrangements vary and must be arranged in advance with the practice manager. Pre-paid sessions are non-refundable.

As required by the No Surprises Act (45 CFR § 149.610), you have the right to a Good Faith Estimate of expected charges before services begin. Your GFE will be provided at intake. You will not be billed more than $400 above your GFE without prior written notice. Dispute rights apply.

All clinical communication must go through Healthie secure messaging — the only HIPAA-compliant channel. Office phone/text: (480) 382-6109. General inquiries: [email protected]. Do not share sensitive health information via personal email, SMS, or social media. For medical emergencies: call 911.

All clinical information is governed by HIPAA and Arizona state law. Sharing requires a signed Release of Information. Mandatory reporting exceptions apply as required by law.

All clinical content, tools, frameworks, meal plans, assessments, and materials produced by Kristine Sinner and Sinnergy Wellness Group are proprietary intellectual property. The R.E.S.T.O.R.E. MNT system is owned exclusively by Kristine Sinner. Unauthorized reproduction, distribution, or commercial use of any clinical materials is strictly prohibited. © 2026 Kristine Sinner / Sinnergy Wellness Group. All rights reserved.

By signing below, I authorize Sinnergy Wellness Group to store my payment method on file in Healthie (PCI-DSS compliant) and to charge the card on file for:

• Session fees as agreed at scheduling, due at or before each session
• Late cancellation and no-show fees equal to the full session rate
• Outstanding balances unpaid after 14 days

I understand that: (1) I will receive an email receipt for every charge; (2) I may update my card at any time through Healthie or by contacting the office; (3) this authorization remains in effect until revoked in writing or the therapeutic relationship ends; (4) pre-paid sessions are non-refundable.

All appointment changes or cancellations must be made at least 24 hours in advance via one of these methods:

1. Cancel or reschedule directly in your Healthie client portal.
2. Send a secure message to the Practice Manager through Healthie.
3. Call or text the office at (480) 382-6109.
4. Email [email protected]

Late cancellations (under 24 hours) and no-shows will be charged the full session rate to the card on file. No exceptions. Pre-paid credits and discounted packages cannot be used to cover these fees.

Three or more late cancellations or no-shows within any 90-day period may result in administrative discharge and forfeiture of unused pre-paid sessions.

Kristine Sinner is available: Tuesdays, Thursdays, and Saturdays. All emails go to [email protected]. Office phone/text: (480) 382-6109. Responses are provided during business hours.

Healthie secure messaging is the only HIPAA-compliant channel for clinical communication. Do not send health information via personal text, email, or social media. Between-session messages are for brief, simple questions only. For matters requiring extended discussion, please schedule a 15-minute check-in.

For urgent clinical matters: call/text (480) 382-6109. For medical or psychiatric emergencies: call 911.

Active individual clients have access to food diary, workout log, and journal features in Healthie. These are personal tools reviewed during sessions. Your provider may comment occasionally but cannot guarantee between-session review. Do not use these features to communicate anything requiring a timely response.

Sinnergy Wellness Group maintains a professional presence on social media to share general nutrition education, wellness content, and practice information. This policy governs how the provider and clients interact in digital spaces to protect therapeutic boundaries, client privacy, and the integrity of the clinical relationship.

The official Sinnergy Wellness Group accounts on Instagram, TikTok, Facebook, LinkedIn, YouTube, and X (Twitter) are used for general public education only. Content posted by the practice does not constitute clinical advice or a therapeutic relationship. If you have clinical questions, please contact the office through the appropriate channels.

To protect your privacy and the therapeutic relationship, your provider will not accept follow requests, friend requests, or connection requests from current or former clients on any personal or professional social media platform. This boundary applies regardless of the platform and is not a reflection of the quality of your therapeutic relationship.

If you choose to follow the official practice account(s), please be aware that your engagement (likes, comments, shares) is visible to other users. We recommend exercising caution to protect your own privacy.

Please do not tag, mention, or publicly identify Sinnergy Wellness Group, R.E.S.T.O.R.E. MNT, or Kristine Sinner in any social media posts related to your personal health, treatment, or clinical experience. This protects your own privacy (others may make inferences about your health) and maintains the confidentiality of the therapeutic relationship.

Posting or sharing any clinical content, meal plans, handouts, tools, assessments, or materials provided to you as part of your care is strictly prohibited. All such materials are proprietary intellectual property of Kristine Sinner and Sinnergy Wellness Group.

We appreciate feedback and encourage you to share your experience through appropriate channels. If you choose to post a public review on Google, Yelp, or similar platforms, we ask that you do not include any information that could identify other clients or disclose clinical details. We cannot respond to reviews in a way that confirms or discusses any aspect of the therapeutic relationship due to HIPAA.

Messages sent via Instagram DM, Facebook Messenger, TikTok, or any other social media platform are not monitored for clinical purposes, not HIPAA compliant, and will not receive clinical responses. For all clinical communication, use Healthie secure messaging exclusively.

Social media is never an appropriate channel for communicating a crisis or safety concern. If you are in crisis, call 988, call 911, or go to your nearest emergency room immediately.

All content, systems, frameworks, tools, forms, and clinical materials produced by Sinnergy Wellness Group and R.E.S.T.O.R.E. MNT are proprietary and protected by copyright. Reproduction, distribution, resale, or use outside of your personal care is strictly prohibited without written consent. © 2026 Kristine Sinner / Sinnergy Wellness Group.