Dear Valued Client,
The following document describes the Strength Smith Training Systems LLC policy for how information about you may be used and disclosed, how you can get access to this information and how your privacy is being protected. In order to maintain the level of service that you expect from Strength Smith Training Systems LLC, we may need to share limited personal health information with other health and wellness practitioners that you authorize.
Safeguards in place at Strength Smith Training Systems LLC include:
● Limited access to where information is stored
● Policies and procedures for handling information
● Requirements for third parties to contractually comply with privacy laws
● All health files and records are kept on permanent file
In administering your health care, Strength Smith Training Systems LLC gathers and maintains information that may include non-public personal information:
● From your health history, notes, test results, and any letters, faxes, emails or telephone conversations to, or from, other health & wellness practitioners
● From health & wellness providers
In certain states, you may be able to access and correct personal information we have collected about you. We value your relationship and respect your right to privacy. The following information describes Your Rights, Your Choices and Our Uses and Disclosure policies - A detailed list is available upon request.
At Strength Smith Training Systems LLC you have the right to:
● Obtain a copy of, or correct, your paper or electronic health and wellness records
● Request confidential communication
● Ask us to limit the information we share
● Get a list of those with whom we have shared your information
● Choose someone to act for you
● File a complaint if you believe your privacy rights have been violated
At Strength Smith Training Systems LLC you have some choices in the way we use and share information as we:
● Tell family and friends about your health and wellness
● Include you in a directory
● Market our services
Our Uses and Disclosures - We may need to use and share your information as Strength Smith Training Systems LLC:
● Consults you
● Bills for your services
● Performs research
● Complies with the law
● Responds to lawsuits and legal actions
I hereby give consent for coaching and consulting by Strength Smith Training Systems LLC and accept full financial responsibility for all services performed
A. Headings & Severability - Headings are included for convenience purposes only and shall not affect the construction of this Agreement. If any portion of this Agreement is held to be unenforceable, it shall not affect the remaining portions of the Agreement, which shall remain in full effect. If any portion of this Agreement is held to be unenforceable, then the unenforceable portion shall be construed in compliance with applicable law in a light most favorable to the original intentions of the parties. If the unenforceable portion of the Agreement is found by a competent court of this jurisdiction to be contrary to law, then it shall be changed and interpreted to best reflect the original intentions of the parties, and all other provisions shall remain in full force and effect.
B. Entire Agreement - This Agreement reflects the entire agreement between the parties. This Agreement trumps any other existing negotiations, communications or Agreements between the parties, whether written, oral, or electronic, and is the full extent of the Agreement between the parties.
C. Governing Law – OWNER is located in the United States and is subject to the applicable laws governing the United States. The governing law for this agreement is the laws of the State of Arizona.
D. Arbitration - Any disputes arising under this Agreement shall first be resolved through a binding arbitration.
E. Execution - This Agreement may be signed in counterparts. Signatures sent via facsimile and electronic signatures (for example, “/s/
from a personally-identifiable address with acknowledgement and consent), shall be deemed valid.
Consent for Purposes of Coaching and Consulting, Payment and Health and Wellness Operation Informed Consent to Consulting:
I consent to the use or disclosure of my identifiable health information by Strength Smith Training Systems LLC for the purposes of health and wellness coaching and consulting to, obtaining payment for my consulting bills or to conduct health consulting activities. I understand, health and wellness coaching and consulting through Strength Smith Training Systems LLC may be conditional upon my consent as evidenced by my signature on this document. I understand I have the right to request a restriction as to how my identifiable health and wellness information is used or disclosed to carry out payment or health and wellness consulting operations of the practice. Strength Smith Training Systems LLC is not required to agree to the restrictions that I may request. However, if Strength Smith Training Systems LLC agrees to a restriction I request, the restriction is binding upon Strength Smith Training Systems LLC. I have the right to revoke this consent, in writing, at any time except to the extent Strength Smith Training Systems LLC has taken action in reliance on this consent.
My identifiable health and wellness information means health information, including my demographic information, collected from me and created, or received, by my practitioner or another health and wellness provider. This identifiable health and wellness information relates to my past, present or future physical or mental health, or condition, and identifies me, or there is a reasonable basis to believe the information may identify me.
Privacy rules provide individuals the right to request a restriction on uses and disclosures of their protected health information. The individual is also provided the right to request confidential communication be made by a specific means.
I understand that I am the decision maker for my health care. Part of this office’s role is to provide me with information to assist me in making informed choices. This process is often referred to as “informed consent” and involves my understanding and agreement regarding the care recommended, the benefits and risks associated with the care, alternatives, and the potential effect on my health if I choose not to receive the care. Acupuncture is not intended to substitute for diagnosis or treatment by medical doctors or to be used as an alternative to necessary
medical care. It is expected that you are under the care of a primary care physician or medical specialist, that pregnant patients are being managed by an appropriate healthcare professional, and that patients seeking adjunctive cancer support are under the care of an oncologist.
I hereby request and consent to the performance of acupuncture treatments and other procedures within the scope of the practice of acupuncture on me (or on the patient named below, for whom I am legally responsible) by the acupuncturist indicated below and/or other licensed acupuncturists who now or in the future treat me while employed by, working or associated with, or serving as back-up for the
acupuncturist named below, including those working at the clinic or office listed below or any other office or clinic, whether signatories to this form or not.
I understand that methods of treatment may include, but are not limited to, acupuncture, moxibustion, cupping, electrical stimulation, Tui-Na (Chinese massage), Chinese herbal medicine, and nutritional counseling. I understand that the herbs may need to be prepared and the teas consumed according to the instructions provided orally and in writing. The herbs may have an unpleasant smell or taste. I will immediately notify a member of the clinical staff of any unanticipated or unpleasant effects associated with the consumption of the herbs.
I appreciate that it is not possible to consider every possible complication to care. I have been informed that acupuncture is a generally safe method of treatment, but, as with all types of healthcare interventions, there are some risks to care, including, but not limited to: bruising; numbness or tingling near the needling sites that may last a few days; and dizziness or fainting. Burns and/or scarring are a potential risk of
moxibustion and cupping, or when treatment involves the use of heat lamps. Bruising is a common side effect of cupping. Unusual risks of acupuncture include nerve damage and organ puncture, including lung puncture (pneumothorax). Infection is another possible risk, although the clinic uses sterile disposable needles and maintains a clean and safe environment.
I understand that while this document describes the major risks of treatment, other side effects and risks may occur. The herbs and nutritional supplements (which are from plant, animal, and mineral sources) that have been recommended are traditionally considered safe in the practice of Chinese Medicine, although some may be toxic in large doses. I understand that some herbs may be inappropriate during pregnancy. I will notify a clinical staff member who is caring for me if I am, or become, pregnant or if I am nursing. Should I become pregnant, I will discontinue
all herbs and supplements until I have consulted and received advice from my acupuncturist and/or obstetrician. Some possible side effects of taking herbs are: nausea; gas; stomachache; vomiting; liver or kidney damage; headache; diarrhea; rashes; hives; and tingling of the tongue.
While I do not expect the clinical staff to be able to anticipate and explain all possible risks and complications of treatment, I wish to rely on the clinical staff to exercise judgment during the course of treatment which the clinical staff thinks at the time, based upon the facts then known, is in my best interest. I understand that, as with all healthcare approaches, results are not guaranteed, and there is no promise to cure.
I understand that I must inform, and continue to fully inform, this office of any medical history, family history, medications, and/or supplements being taken currently (prescription and over-the-counter). I understand the clinical and administrative staff may review my patient records and lab reports, but all my records will be kept confidential and will not be released without my written consent.
I understand that there are treatment options available for my condition other than acupuncture procedures. These options may include, but are not limited to: self-administered care, over-the-counter pain relievers, physical measures and rest, medical care with prescription drugs, physical therapy, bracing, injections, and surgery. Lastly, I understand that I have the right to a second opinion and to secure other options about my circumstances and healthcare as I see fit.
By voluntarily signing below, I confirm that I have read, or have had read to me, the above consent to treatment, have been told about the risks and benefits of acupuncture and other procedures, and have had an opportunity to ask questions. I agree with the current or future recommendations for care. I intend this consent form to cover the entire course of treatment for my present condition and for any future
condition(s) for which I seek treatment.
Both parties agree that this agreement may be electronically signed, and that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.