MARY ANN HODOROWICZ CONSULTING, LLC
Nutrition, Diabetes Education, Health Promotion and Insurance Reimbursement for Professionals For the Healthcare and Food Industry
 
N e e d s      and       g o a l s        A s s e s s m e n t

Date:                                            Best day(s) to contact you (circle)  M  —  Tu  —  W  —  Th  —  F  —  Sa  --  Su                                 

Best times to contact you:                                                       May I call you in the early evening?    YES      NO
                                                                                                    May I call you on Sat. or Sunday?       YES      NO

Name:                                                     Credentials:                              

Position Title:                                                                                   
                                      
Business/Company/Association/Program Name:  
		
Street Address :

City:                                             State:                                      Zip:                                 Time Zone:

Work No.:                                    Cell No.:                                 Fax:                                 Home No.:                             

E-mail:                                                                               Web site address:
                                                                        
Place of Employment CATEGORY (check all that apply):   
             __Business/commercial company (for profit)                                                                   	
             __Health food store	

             __Business/commercial (non-profit) 	
	__Restaurant, cafeteria	

	__Hospital	
	__Private practice/self-employed	

	__Nursing home/long term care	
             __Skilled nursing facility	

	__Clinic/health center	
	__HMO/insurance/other health care	

	__Home health/hospice	
            __Pharmacy	

            __Public health department/rural health center	
	__Government (state, federal)	

	__University, collage, school	
	__Wellness center	

	__Professional membership association	
            __Television, radio station	

            __Physician’s office	
            __Grocery store	

            __Dietetic internship program	
            __Other (specify):	

Major employment AREAS OR responsibilities (check all that apply):
__Business management or supervisor	
__Medical Nutrition Therapy (MNT)	

__Hospital food and nutrition services management 	
__Diabetes Self-Management Education (DSME)	

__ Hospital inpatient clinical nutrition management 	
__Writing, editing, publishing, media work	

__Program director or educator in academia	
__Information technology/communications	

__CDE	
__Marketing and/or public relations	

__Consultant	
__Insurance billing or medical record claims coding	

__Dietitian			
__Community nutrition/nutrition education	

__RN	
__Advocacy/association membership work	

__Account Rep                                                                     	
__Teaching	

__Chef	
__Health promotion, wellness	

__Research	
__Other (specify):	

__Product development   __Product distribution      __Product sales         __Product marketing/advertising  for:
 Food        Nutritional supplements/tube feedings   Package/labels     Medical equipment/supplies  
 Food service supplies   Glucose testing supplies   Drugs, insulin       Vitamin/mineral supplements
 Health/food related magazines    Other:	 

Which categories below are your needs in?  (Check all that apply):                      

  Third Party Reimbursement (Initiating, Maintaining, Increasing) for:
         Medical Nutrition Therapy (MNT) 
         Diabetes Self-Management Training/Education (DSMT, DSME)
         Medical Nutrition Therapy (MNT)
         Enteral Nutrition Tube Feedings
•	Parenteral Nutrition Feedings
•	Diabetes/Blood Glucose Testing Supplies
•	Diabetes/Blood Glucose Testing Supplies via Pharmacy Benefit Management
•	Insulin Pump and Training
•	Continuous Blood Glucose Monitoring System
•	In-Office Hemoglobin A1c Test
•	Other (specify):__________________________________________________________________________

            Specific needs are for:   Consulting       Training        Presentation        Article on: 
            ___Medicare reimbursement coverage guidelines 
            ___Private payer reimbursement coverage guidelines
            ___Claims coding
            ___Claims processing
            ___Completing CMS 1500 and/or UB04 claim form
            ___How to become Medicare MNT provider
            ___How to become credentialed provider with private insurance companies 
            ___MNT/DSME superbill
            ___Physician referral/order form
            ___Other (specify):________________________________________________________________________

  DEVELOPING and/or ENHANCING THESE PATIENT ProgramS IN YOUR PRACTICE SETTING 
     (HOSPITAL, CLINIC, PHYSICIAN OFFICE, ETC.):          
       MNT
       DSME
       Weight Loss                                                      
       Diabetes Prevention                                                      
       Nutrition Wellness                                                                                                                    

 DEVELOPING YOUR OWN PRIVATE PRACTICE FOCUSED ON:
       MNT
       DSME
       Weight Loss                                                      
       Diabetes Prevention                                                      
       Nutrition Wellness                                                                                                                

           Specific needs are for :    Consulting            Staff Training         Presentation        Article on   
                                                      Program Development                            Mary Ann to Conduct Program on:

           ___Using “differentiation of nutrition services” model to maximize market share by gaining competitive edge
           ___Detailed business plan for program operations/structure to maximize physician and self-referrals and 
                 patient attendance                                                                               
           ___Outcomes tracking and management
           ___Curriculum for outpatient program
           ___Curriculum for inpatient diabetes survival skills training  
           ___Deciding on which private practice reimbursement model to use (5 different models)           
           ___Electronic (modifiable) forms for program and clinical operations:  DSME    MNT  (patient attendance, 
                 patient assessment, nutrition diagnosis, nutrition prescription, nutrient/calorie calculation per calorie level,     
                 documentation, progress notes, flow sheets, outcome tracking, etc.)
           ___Physician referral/order form
           ___Staffing
           ___Writing program proposal for administration                                                                                                                                                                                                                                       
           ___Program performa and budget
           ___Marketing, advertising plan 
           ___Increasing physician referrals                                                                                                                                                                                                                                                                      
           ___Increasing self-referrals and/or program attendees
           ___Decreasing patient appointment “no show” rates
           ___Other (specify):________________________________________________________________________

   Obtaining Recognition for DSME Program (Required for Medicare Billing)
      
       Specific needs are for :   Consulting   Training     Presentation    Article on: 

         National Standards for Diabetes Self-Management Education
         American Association of Diabetes Educators’ new 7 behaviors for diabetes self-management

    PRESENTATIONS TO PROFESSIONALS

        Topic(s) can be selected from list below* or can specify own topic.

        Name of event:____________________________________________________________________________
        Sponsoring organization:_____________________________________________________________________
        Date of event:____________________________ Date of presentation:________________________________                           
        Location of event:__________________________________________________________________________
        Is presentation planned as pre-conference workshop?    __YES    __NO     __MAYBE 
        Will presentation have outside sponsorship?                   __YES    __NO     __MAYBE
        Are CEUs desired?                                                           __YES    __NO     __MAYBE       
        Time frame for presentation (minutes/hours):_____________________________________________________
        Attendees level of understanding of topic is assumed to be: __minimal __moderate __advanced
        
•	Specific topics (Mary Ann’s signature presentations):

o	 Money Matters in MNT and DSME: Increasing Reimbursement Success in All Practice Settings

o	How to Implement a Successful Hospital-Based or Private Practice MNT Program

o	Diabetes Encounters of the Senior Kind: Unique Self-Management Challenges of the Older Person with Diabetes and Practical Ways to Minimize Them!

o	Zest for Life: Nutrition and Lifestyle for Healthy Aging

o	Update on the Nine Newest Medicare Provisions Impacting MNT Coverage and Utilization and New CPT Codes for RDs Use       

o	T.A.P. into Personal and Professional Potential: A 15 Point Make-Over of Traits, Attitudes and Practices Leading to Extraordinary Success!

o	Patient Empowerment: Proven Model for Enhancing Behavior Change in Patients with Chronic Disease 

o	FINALLY!  A Super Easy, Step-by-Step Guide for Making a Nutrition Diagnosis

o	Critical Connections to Advance Your Career and Your Profession: Performance, Advocacy, Competency and Expertise Sharing

o	Improving the Quality and Effectiveness of Chronic Care Teams (Based on: Institute of Medicine’s Quality Chasm Report; Better Diabetes Care by National Diabetes Education Program;  Breakthrough Series: IHI’s Collaborative Model for Achieving Breakthrough Improvement, ‘04 by Institute of Health Care Improvement)

o	Business Matters: How to Create a Dynamic Business Plan for Building, Maintaining and Growing a Dietitian’s Private Practice

o	How to Successfully Market Your Medical Nutrition Therapy Program and Your Private Practice: Don’t Just Survive, Thrive!

o	“C” How to Increase Referrals and Patient Attendance in Hospital-Based MNT and DSME Programs: Proven Marketing Strategies Guaranteed to Keep Your Program Thriving!

o	If a ‘Best Practice’ Nutrition Department is Your Dream, Then Implementing a “5 Star Quality Management Plan” Should Be Your Passion!  

o	Be a ‘Best Practice’: A Comprehensive Quality Management Plan for MNT and DSME Programs

o	Simplifying and Summarizing the American Dietetic Association’s Medical Nutrition Therapy Evidence-Based Guides for Practice

o	Developing a MNT and DSME Outcomes Management System:  It’s Easier and More Essential Than You Think!

o	A Dietitian’s Business Plan for Implementing a Successful Hospital-Based and/or Private Practice MNT Program

o	Defining Good Business: The Dietitian’s Step-by-Step Guide for Developing a Comprehensive Business Plan for a Private Practice

o	Step-by-Step Guide for Obtaining American Diabetes Association Education Recognition Program Certification for Your Diabetes Education Program

o	How to Establish a Successful Hospital-Based Outpatient MNT Clinic

o	Everything the RD Needs and Wants to Know to Successfully Provide the Medicare MNT Benefit…And Then Some!

o	Getting Paid What You’re Worth in a Physician’s Medical Practice: How the RD Can Determine and Negotiate the Best Business Plan

o	Using and Understanding the Nutrition Care Process and Model

o	Should a Private Practice Dietitian use a Medical Biller?  Crunching the Numbers and Examining the Pros and Cons So You Can Decide!

o	Train the Trainer Workshop on MNT and DSMT Programs: Obtaining Medicare and Private Payer Reimbursement, Increasing Referrals and Attendance and Enhancing Program Efficiency, Viability and Quality

o	Insider Secrets of Successfully Providing Reimbursable Medicare MNT and Therapeutic Diet Meals to Homebound Seniors in an Elderly Nutrition Program: The Time Has Come…Are You Ready?  

o	Business Matters: How to Create a Dynamic Business Plan for Building, Maintaining and Growing Your Facility-Based, Reimbursable MNT Program

o	Six Super Star Metrics” for Evaluating the Performance and Value of Your MNT and DSME Programs…or Why Revenue is only 1/6 of the Programs’ True Value! 

     Any of these PowerPoint® presentations can be customized to fit your needs like a hand in a glove!  They can 
      also be formatted to fit the time frame allotted.  Just ask!   As I self-publish a  manual on MNT and DSME 
      reimbursement, another on establishing a MNT program and also sell electronic MNT and DSME forms, I offer a 
      big discount to conference attendees upon purchasing these resources in the month following my talk.  I also 
      donate several copies of the manuals and the electronic forms for a raffle or door prizes for your meeting!  This is 
      my way of saying thanks for the honor of speaking to your group!

       PRESENTATIONS TO CONSUMERS
          
o	Nutrition in Pre-Dialysis Renal Disease                   
o	Nutrition in Renal Failure                                         
o	Diabetes: S.W.E.E.T.S. Control                               
o	Diabetes Prevention                                                
o	Nutrition in Primary Biliary Cirrhosis                        
o	Weight Loss / Weight Control                                 
o	5 Star Healthy Eating Plan
o	The Skinny on Fad Diets
o	Health Heart Nutrition  
o	Vitamins, Minerals, Supplements: Right for You?
o	Dietary Fats: The Good, The Bad and the Ugly! 
o	The Newest Dietary Guidelines for Healthy Americans      
o	Healthy Restaurant Eating                                   
o	Controlling Eating Triggers: Trigger Foods, Moods and Situations 
o	My other interest is: ____________________________________________________________________                                                                                                                                                           

•	HAVING NUTRITIONALLY BALANCED MENUS WRITTEN FOR (SPECIFY):

         HAVING AN INSTRUCTIONAL MANUAL WRITTEN ON (SPECIFY TOPIC):

•	HAVING MY PRODUCT OR SERVICE EXPERTLY REPRESENTED AND PROMOTED AT:

          Consumer trade show                       Professional trade show
   
              Specify product or service:                                                                                                                                                                                
                                                                                                                                                                  
•	TEACHING DIETETIC STUDENTS  “REAL-WORLD” PRACTICAL SKILLS  (Using ADA’s MNT evidence-based practice guidelines, MNT outcomes management, MNT and diabetes education reimbursement from Medicare and commercial payers, developing a private practice, developing a recognized diabetes self-management education program, constructing a business plan, writing a business proposal, patient empowerment, effective nutrition counseling skills, etc.) 

•	OTHER CONSULTING AND/OR TRAINING NEEDS (SPECIFY):

Which of these parameters meets your needs best?   The Consulting/training is:
        On site         Off site       Telephone conferences        Other (specify):
•	In half-day increments     In whole day increments      Other (specify):
What is your desired time frame for having your needs met? 

What is your firm deadline? 
If your need is for employee TRAINING, approximately about how many will be in attendance?

Other NEEDS, concerns, comments:

OPTIONAL:  How did you learn about MARY ANN HODOROWICZ CONSULTING, LLC?
__web search             __referral            __heard Mary Ann speak          __ADA practice group         __networking
__classified ad in magazine                  __Internet listserv                      __I’m a former patient of Mary Ann’s
__I’m a former or current client of Mary Ann’s   __other (specify):	
                   
anything else?

	
                                                                                                                                                                                                                                                                                  
Thank you for taking the time to complete this form!  Please submit to Mary Ann (see bottom of page).   I will contact you as soon as possible so we can talk further about meeting your needs.

12921 SYCAMORE    PALOS HEIGHTS, IL  60463
Office: 708. 359.3864    hodorowicz@comcast.net    www.maryannhodorowicz.com
Fax: 866.869.6279