AUTHORIZATION FOR RELEASE OF HEALTH INFO

AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION AND REQUIRED NOTICE AND FULL DISCLAIMER AND RELEASE OF LIABILITY

I. Health Information Use
Warriors for Wellness (“We,” “Us” or “Our”) is dedicated to maintaining the privacy of your Health Information and is providing you with this Authorization for Release of Health Information and Required Notice (“Notice”) regarding the collection of your Health Information. Health Information includes, but is not limited to: the results of, or participation in wellness coaching sessions, questionnaires, exercises, general wellness education or services; medical history; or information protected under the Health Insurance Portability and Accountability Act of 1996, Public Law 104-91, as amended, and related HIPAA regulations (45 CFR. Parts 160-164). We may collect Health Information from you as part of the Services provided. Services include but are not limited to: flexibility classes, wellness and stress management coaching sessions, questionnaires, exercises, mindfulness practices, general wellness education, and general wellness education related to the management of chronic pain/fatigue and chronic illness.
We want to collect your Health Information and shall use it for Our business purposes to provide you with the Services you requested. We will not use or disclose your Health Information, unless you have provided written authorization, or as permitted or required by law or regulation. We will securely store your Health Information and will not permit unauthorized access to your Health Information. Access to your Health Information by Us shall be limited to the minimum necessary required for business purposes.
Additionally, with your authorization, We would like to use a portion of your Health Information when We engage in social media and business practices. This portion of Health Information is limited to your images, video, recording, or Service testimonials, only. Social media includes, but is not limited to: Facebook, Twitter, Instagram, YouTube, Snapchat, blogs, and Our webpage.

II. Authorization and Release
BASED ON THE ABOVE, I hereby voluntarily agree to provide Health Information.
to Warriors for Wellness Corporation. I attest by checking the associated box for the AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION AND REQUIRED NOTICE and by signing the AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION AND REQUIRED NOTICE AND FULL DISCLAIMER AND RELEASE OF LIABILITY FORM (CLIENT INITIAL INTAKE FORM 1), that Warriors for Wellness has explained, and I understand the specific types of Health Information they are asking me to provide, how they intend to use it in the Services, and proper notice has been given. I also attest that I understand the restrictions on use and disclosure of my Health Information once provided.

FULL DISCLAIMER & RELEASE OF LIABILITY

GENERAL INFORMATION
You, the Client, (the “Client”) acknowledge and understand that practitioners at Warriors for Wellness, incorporated in the state of OHIO (the "Company," “We,” “Us,” or “Our”)are not Medical Doctors or mental health therapists and do not practice medicine as licensed physicians prescribing, diagnosing, or treating diseases of the human body and do not practice mental health therapy as licensed psychologists or counselors. The Client further acknowledges that the services provided by Us do not involve the diagnosing of disease or prescribing of medicine for treatment of disease.
The Client acknowledges and understands that Our services are designed to teach tools and provide guidance to make positive changes and live a healthy lifestyle. Our services may include coaching from unlicensed providers.
Reaching optimal health requires sincere commitment, possible lifestyle changes, and a positive attitude. If you are not prepared to make lifestyle changes, Company may not be the right approach for you. Since every human being is unique on a biochemical level, Company cannot guarantee any specific results.
HEALTH CONCERNS
If you suﬀer from a medical condition, you must consult with an appropriate healthcare provider. While health and wellness tools can provide a host of benefits to sustain a healthy lifestyle, it is not a substitute for your family physician or other appropriate healthcare provider.
While some Company practitioners may be trained or licensed to diagnose or treat pathological conditions, illnesses, injuries, or diseases or prescribe medications, they will not be functioning in that capacity.
If you are under the care of another healthcare provider, it is important that you alert them to your participation in Company’s activities. Our health and wellness services may be a beneficial adjunct to traditional medical care, but it is not a substitute. If you have any health concerns, medical conditions, or take any medications, you must alert Us before participating.
Notice to pregnant women: all female patients must alert Us if they know or suspect hat they are pregnant, since some of the activities could present a risk to the pregnancy. You should also consult with your primary physician/obstetrician before participating in any Company activities.
HIPPA POLICY
During the course of your participation in Company activities, your coach may ask you to provide relevant personal details and information relating to your background, health, lifestyle, etc. (hereafter referred to as “Information”), including but not limited to:

Your full name, physical address, email address, phone number, date of birth, etc.
Your health history, including injuries, surgeries, prescriptions, etc. This Information will be gathered from you via interviews, questionnaires, evaluations, intake documents, phone, email, mail, video conferences, etc., and used to:
- Help assess your nutritional needs;
- Assess your physical limitations and overall health behaviors;
- Make recommendations for dietary changes and nutritional supplements to support your specific nutritional needs and goals;
- Comply with all legal obligations.

Though Company is not a HIPAA-regulated entity, We are committed to protecting client privacy and uphold the privacy best practices and the policies laid out in the U.S. Standards for Privacy of Individually Identifiable Health Information, in addition to our Website Social Media Policies/Terms and Conditions
We will take all reasonable steps to protect your Information from unauthorized access, use, or disclosure by using strong passwords, up-to-date software on all devices, and locking file cabinets for physical documents.
However, even the best security practices cannot guarantee that all stored data will be completely free from third-party interception or corruption. In accordance with Standards for Privacy of Individually Identifiable Health Information, your consent is required for Company to collect, use, and disclose your personal Information.

I attest by checking the associated box for the FULL DISCLAIMER AND RELEASE OF LIABILITY and by signing the CLIENT INITIAL INTAKE FORM 1, that I acknowledge consent for Company to collect my Information. and I confirm that I have read and fully understand the above disclaimer, am in complete agreement thereto, and do freely and without duress sign and consent to all terms contained herein:

RELEASE OF LIABILITY

I, THE CLIENT, ACKNOWLEDGE AND UNDERSTAND THAT I AM VOLUNTARILY PARTICIPATING IN THE SERVICES (HEREAFTER “ACTIVITIES”) PROVIDED BY COMPANY WITH KNOWLEDGE OF THE RISKS INVOLVED AND HEREBY AGREE TO ACCEPT AND ASSUME ANY AND ALL RISKS OF INJURY, DEATH CAUSED, OR PROPERTY DAMAGE BY THE NEGLIGENCE OF COMPANY, ITS OFFICERS, DIRECTORS, EMPLOYEES, AGENTS, AFFILIATES, SHAREHOLDERS, SUCCESSORS, AND ASSIGNS ("COLLECTIVELY, "RELEASEES”).
I ACCEPT FULL RESPONSIBILITY FOR ANY PERSONAL INJURY WHICH MAY RESULT FROM MY PARTICIPATION IN ANY COMPANY ACTIVITY, AND HEREBY HOLD HARMLESS COMPANY FOR ANY PERSONAL INJURY SUSTAINED BY ME, INCLUDING DEATH, CAUSED BY THE NEGLIGENCE OF ANY COMPANY RELEASEES. I HEREBY EXPRESSLY WAIVE AND RELEASE ANY AND ALL CLAIMS BASED IN NEGLIGENCE AGAINST COMPANYAND RELEASEES ON ACCOUNT OF INJURY OR DEATH ARISING OUT OF OR ATTRIBUTABLE TO MY PARTICIPATION IN THE ACTIVITIES.

NOTHING IN THIS RELEASE SHOULD BE CONSTRUED AS RELEASING, DISCHARGING, OR WAIVING ANY CLAIMS THE CLIENT MAY HAVE FOR RECKLESS OR INTENTIONAL ACTS ON THE PART OF ANY COMPANY RELEASEE.

This RELEASE OF LIABILITY (hereafter “Agreement”) constitutes the sole and entire agreement of Company and me, the Client, with respect to the subject matter contained herein and supersedes all prior and contemporaneous understandings, agreements, representations, and warranties, both written and oral, with respect to such subject matter. If any term or provision of this Agreement is invalid, illegal, or unenforceable in any jurisdiction, such invalidity, illegality, or unenforceability shall not affect any other term or provision of this Agreement or invalidate or render unenforceable such term or provision in any other jurisdiction. This Agreement is binding on and shall inure to the benefit of the Company and me, the Client, and our respective successors and assigns.

Miscellaneous Terms

Entire Agreement: This Agreement constitutes the entire agreement between the Parties and supersedes all prior agreements, communications, and writings, whether written or oral, between the Parties. The terms and conditions of this Agreement may only be amended by mutual written agreement of the Parties. No other modification, amendment or addition to this Agreement will be valid or enforceable unless in writing and signed by the Parties.
Headings: The headings in this Agreement are for convenience of reference only, and under no circumstances should they be construed as being a substantive part of this Agreement nor shall they limit or otherwise affect the meaning thereof.
Severability: If any provision of this Agreement is held invalid or unenforceable the remaining provisions and paragraphs shall continue in full force and effect and shall be binding on the Parties.
No Assignment: You shall not assign any rights, or delegate or subcontract any obligations, under this Agreement without Our prior written consent. Any assignment in violation of the above shall be deemed null and void. We may freely assign Our rights and obligations under this Agreement at any time. Subject to the limits on assignment stated above, this Agreement will inure to the benefit of, be binding on, and be enforceable against each of the Parties and their respective successors and assigns.
No Waiver: The waiver by either Party of a breach or violation of any provision in this Agreement shall not operate or be construed as a waiver of any subsequent breach or default of a similar nature, or as a waiver of any such provisions, rights, or privileges. Failure to insist upon full performance of the obligation or failure to exercise rights under this Agreement shall not constitute a waiver as to future defaults or exercise of rights.

Governing Law: This Agreement shall be governed, construed, and enforced in accordance with the substantive laws of the State of OHIO, without regard to its choice of law provisions.
Arbitration: Any dispute, claim, or controversy arising out of or relating to this Agreement or the breach, termination, enforcement, interpretation or validity thereof, including the determination of the scope or applicability of this Agreement to arbitrate, shall be determined by arbitration in WARREN COUNTY, OHIO before one (1) arbitrator. The arbitration shall be administered by AHLA Alternative Dispute Resolution Service Rules of Procedure for Arbitration, in WARREN COUNTY, OHIO.
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Judgment on the award may be entered in any court having jurisdiction. This provision shall not preclude either Party from seeking provisional remedies in aid of arbitration from a court of appropriate jurisdiction. The arbitrator may, in the award, allocate all or part of the costs of the arbitration, including the fees of the arbitrator. You agree to submit any claims arising out of this Agreement to binding arbitration, and this dispute resolution provision constitutes a waiver of Your right to a jury trial. HOWEVER, prior to the Parties initiating Arbitration the Parties agree to attempt mediation of the dispute with a mutually agreeable trained mediator in WARREN COUNTY, OHIO. “Trained mediator” means a professional with actual training and experience in the field of Mediation and/or dispute resolution.

Email: info@warriors4wellness.org

Website: Warriors4wellness.org

By checking the associated box for the FULL DISCLAIMER AND RELEASE OF LIABILITY AND SIGNING THE AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION AND REQUIRED NOTICE AND FULL DISCLAIMER AND RELEASE OF LIABILITY FORM (CLIENT INITIAL INTAKE FORM 1), I AM ACKNOWLEDGING THAT I HAVE BEEN GIVEN THE OPPORTUNITY TO BARGAIN WITH RESPECT TO MY RIGHTS UNDER THIS CONTRACT. BY SIGNING, I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTAND ALL OF THE TERMS OF THIS AGREEMENT AND DISCLAIMER, AND THAT I AM VOLUNTARILY GIVING UP SUBSTANTIAL LEGAL RIGHTS, INCLUDING THE RIGHT TO SUE COMPANY OR ITS RELEASEES, AND I CONFIRM THAT i AM IN COMPLETE AGREEMENT THERTO, AND DO FREELY AND WITHOUT DURESS SIGN AND CONSENT TO ALL TERMS CONTAINED THERIN:

*If in agreement, exit this page or use the "back button", check the associated box for AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION AND REQUIRED NOTICE and FULL DISCLAIMER AND RELEASE OF LIABILITY, and sign the CLIENT INITIAL INTAKE FORM 1.