Dear Valued Client,

Strength Smith Training Systems LLC Client Privacy Policy
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 acupuncturists, and/or 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

MISCELLANEOUS
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 Acupuncture Treatment, 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 acupuncture treatnemt, health and wellness coaching and consulting to, obtaining payment for my treatment and/or consulting bills or to conduct acupuncture and/or health consulting activities. I understand, acupuncture, 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 acupuncture and/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 and/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.

I understand I have the right to review the Strength Smith Training Systems LLC Notice of Privacy Policy prior to signing this document. The Notice of Privacy Policy describes the types of uses and disclosures of my identifiable health and wellness information that will occur in my acupuncture treatment and/or health and wellness coaching and consulting, payment of my bills or in the performance of acupuncture treatment and/or health and wellness coaching and consulting operations of Strength Smith Training Systems LLC. This Notice of Privacy Policy also describes my rights and the duties of my coach/consultant and Strength Smith Training Systems LLC with respect to my identifiable health and wellness information. Strength Smith Training Systems LLC reserves the right to change information contained in the Notice of Privacy Policy at any time. I may obtain a revised Notice of Privacy Policy by requesting the most current notice during any acupuncture treatment and/or health and wellness consultation meeting.

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.

Arbitration Agreement

Article 1: Agreement to Arbitrate: It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by submission to arbitration as provided by state and federal law, and not by a lawsuit or resort to court process, except as state and federal law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration. Further, the parties will not have the right to participate as a member of any class of claimants, and there shall be no authority for any dispute to be decided on a class action basis. An arbitration can only decide a dispute between the parties and may not consolidate or join the claims of other persons who have similar claims.

Article 2: All Claims Must be Arbitrated: It is also understood that any dispute that does not relate to medical malpractice, including disputes as to whether or not a dispute is subject to arbitration, as to whether this agreement is unconscionable, and any procedural disputes, will also be determined by submission to binding arbitration. It is the intention of the parties that this agreement bind all parties as to all claims, including claims arising out of or relating to treatment or services provided by the healthcare provider, including any heirs or past, present or future spouse(s) of the patient in relation to all claims, including loss of consortium. This agreement is also intended to bind any children of the patient whether born or unborn at the time of the occurrence giving rise to any claim. This agreement is intended to bind the patient and the healthcare provider and/or other licensed healthcare providers, preceptors, or interns who now or in the future treat the patient while employed by, working
or associated with or serving as a back-up for the healthcare provider, including those working at the healthcare provider’s clinic or office or any other clinic or office whether signatories to this form or not. All claims for monetary damages exceeding the jurisdictional limit of the small claims court against the healthcare provider, and/or the healthcare provider’s associates, association, corporation, partnership, employees, agents and estate, must be arbitrated including, without limitation, claims for loss of consortium, wrongful death, emotional distress, injunctive relief, or punitive damages. This agreement is intended to create an open book account unless and until revoked.

Article 3: Procedures and Applicable Law: A demand for arbitration must be communicated in writing to all parties. Each party shall select an arbitrator (party arbitrator) and provide National Arbitration and Mediation (“NAM”) with the party arbitrator’s contact information within thirty days of the date Respondent files its initial responsive pleading. A third arbitrator (neutral arbitrator) shall be selected by the arbitrators appointed by the parties from a list of arbitrators supplied by National Arbitration and Mediation (“NAM”) within thirty days thereafter. The list supplied by NAM shall be a list of between 5 and 10 arbitrators, depending upon availability. The neutral arbitrator shall then be the sole arbitrator and shall decide the arbitration. Each party to the arbitration shall pay such party’s equal share of the expenses and fees of the neutral arbitrator, together with other expenses of the arbitration incurred or approved by the neutral arbitrator, not including counsel fees, witness fees, or other expenses incurred by a party for such party’s own benefit. Either party shall have the absolute right to bifurcate the issues of liability and damages upon written request to the neutral arbitrator. The parties consent to the intervention and joinder in this arbitration of any person or entity that would otherwise be a proper additional party in a court action, and upon such intervention and joinder, any existing court action against such additional person or entity shall be stayed pending arbitration. The parties agree that provisions of state and federal law, where applicable, establishing the right to introduce evidence of any amount payable as a benefit to the patient to the maximum extent permitted by law, limiting the right to recover non-economic losses, and the right to have a judgment for future damages conformed to periodic payments, shall apply to disputes within this Arbitration Agreement. The parties further agree that, where not in conflict with this agreement, the Healthcare Malpractice Dispute Resolution Rules and Procedures of NAM shall govern any arbitration conducted pursuant to this Arbitration Agreement. A copy of NAM rules are available on its website at https://www.namadr.com or by calling 1-800-358-2550 to request a copy of the rules.

Article 4: General Provision: All claims based upon the same incident, transaction, or related circumstances shall be arbitrated in one proceeding. A claim shall be waived and forever barred if (1) on the date notice thereof is received, the claim, if asserted in a civil action, would be barred by the applicable legal statute of limitations, or (2) the claimant fails to pursue the arbitration claim in accordance with the procedures prescribed herein with reasonable diligence.

Article 5: Revocation: This agreement may be revoked by written notice delivered to the healthcare provider within 30 days of signature and, if not revoked, will govern all professional services received by the patient and all other disputes between the parties.

Article 6: Retroactive Effect: If patient intends this agreement to cover services rendered before the date it is signed (for example, emergency
treatment), patient should initial here. _______. Effective as of the date of first professional services.
If any provision of this Arbitration Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision. I understand that I have the right to receive a copy of this Arbitration Agreement. By my signature below, I acknowledge that I have received a copy.

NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT.

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.

 

Cancellation

When there is a last-minute cancellation, this prevents Strength Smith Training Systems LLC from offering that time to another client and results in a loss of income. For this reason, we ask that all clients understand the following:

Please plan to be ready 5 minutes early for your scheduled session in order to ensure a full treatment!

-You may cancel your appointment without charge 24 hours before your scheduled appointment.

-Cancellations with less than 24 hour notice will be charged the full scheduled service price.

-If you arrive after your session is scheduled to begin, no additional time will be added to the end of your session to compensate for lost time.

Please sign below to acknowledge that you read, understand, and agree to terms listed in this Cancellation Policy.

Thank you for your understanding and cooperation!