✪ I understand that the massage given to me by a representative of the Antares Wellness PLLC is for the purpose of (stress reduction, pain reduction, relief from muscle tension, increasing circulation, or specific reasons stated here).
✪ I understand that the massage therapist does not diagnose illness or disease and does not prescribe medical treatment or pharmaceuticals, nor are spinal manipulations part of massage therapy.
✪ I understand that massage therapy is not a substitute for medical care and that it is recommended that I work with my primary caregiver for any condition I may have.
✪ I have stated all my known physical conditions and medications, and I will keep the massage therapist updated on any changes.
I have received and read a copy of the HIPPA Notice of Privacy and declined a copy Yes No
You understand that if you cancel your appt less than 24 hours before your appoitment, you will pay the full price of a session Yes No
In consideration of the risk of injury while participating in activities on the premises of the Antares Wellness PLLC , and as consideration for the right to participate in the Activity, I hereby, for myself, my heirs, executors, administrators, assigns, or personal representatives, knowingly and voluntarily enter into this waiver and release of liability and hereby waive any and all rights, claims or causes of action of any kind whatsoever arising out of my participation in the Activity, and do hereby release and forever discharge The Antares Wellness PLLC , located at 9319 7th Ave S Seattle WA 98108, their affiliates, managers, members, agents, attorneys, staff, volunteers, heirs, representatives, predecessors, successors and assigns, for any physical or psychological injury, including but not limited to illness, paralysis, death, damages, economical or emotional loss, that I may suffer as a direct result of my participation in the aforementioned Activity, including traveling to and from an event related to this Activity.
I am voluntarily participating in the aforementioned Activity and I am participating in the Activity entirely at my own risk. I am aware of the risks associated with traveling to and from as well as participating in this Activity, which may include, but are not limited to, physical or psychological injury, pain, suffering, illness, disfigurement, temporary or permanent disability (including paralysis), economic or emotional loss, and death. I understand that these injuries or outcomes may arise from my own or others' negligence, conditions related to travel, or the condition of the Activity location(s). Nonetheless, I assume all related risks, both known or unknown to me, of my participation in this Activity, including travel to, from and during this Activity.
I agree to indemnify and hold harmless The Antares Wellness PLLC against any and all claims, suits or actions of any kind whatsoever for liability, damages, compensation or otherwise brought by me or anyone on my behalf, including attorney's fees and any related costs, if litigation arises pursuant to any claims made by me or by anyone else acting on my behalf. If The Antares Wellness PLLC incurs any of these types of expenses, I agree to reimburse The Antares Wellness PLLC .
I acknowledge that The Antares Wellness PLLC and their directors, officers, volunteers, representatives and agents are not responsible for errors, omissions, acts or failures to act of any party or entity conducting a specific event or activity on behalf of The Antares Wellness PLLC .
I acknowledge that this Activity may involve a test of a person's physical and mental limits and may carry with it the potential for death, serious injury, and property loss. The risks may include, but are not limited to, those caused by terrain, facilities, temperature, weather, lack of hydration, condition of participants, equipment, vehicular traffic and actions of others, including but not limited to, participants, volunteers, spectators, coaches, event officials and event monitors, and/or producers of the event.
I acknowledge that I have carefully read this "waiver and release" and fully understand that it is a release of liability. I expressly agree to release and discharge The Antares Wellness PLLC and all of its affiliates, managers, members, agents, attorneys, staff, volunteers, heirs, representatives, predecessors, successors and assigns, from any and all claims or causes of action and I agree to voluntarily give up or waive any right that I otherwise have to bring a legal action against The Antares Wellness PLLC for personal injury or property damage.
To the extent that statute or case law does not prohibit releases for negligence, this release is also for negligence on the part of The Antares Wellness PLLC , its agents, and employees.
In the event that I should require medical care or treatment, I agree to be financially responsible for any costs incurred as a result of such treatment. I am aware and understand that I should carry my own health insurance.
In the event that any damage to equipment or facilities occurs as a result of my or my family's willful actions, neglect or recklessness, I acknowledge and agree to be held liable for any and all costs associated with any actions of neglect or recklessness.
This Agreement was entered into at arm's-length, without duress or coercion, and is to be interpreted as an agreement between two parties of equal bargaining strength. Both the Participant and The Antares Wellness PLLC agree that this Agreement is clear and unambiguous as to its terms, and that no other evidence will be used or admitted to alter or explain the terms of this Agreement, but that it will be interpreted based on the language in accordance with the purposes for which it is entered into.
In the event that any provision contained within this Release of Liability shall be deemed to be severable or invalid, or if any term, condition, phrase or portion of this agreement shall be determined to be unlawful or otherwise unenforceable, the remainder of this agreement shall remain in full force and effect, so long as the clause severed does not affect the intent of the parties. If a court should find that any provision of this agreement to be invalid or unenforceable, but that by limiting said provision it would become valid and enforceable, then said provision shall be deemed to be written, construed and enforced as so limited.
I, the undersigned participant, affirm that I am of the age of 18 years or older, and that I am freely signing this agreement. I certify that I have read this agreement, that I fully understand its content and that this release cannot be modified orally. I am aware that this is a release of liability and a contract and that I am signing it of my own free will.
HIPPA Notice of Privacy Practice Summary
This summary discloses how health information about you may be used. A full notice of your privacy rights has also been provided to you. Antares Wellness PLLC uses your health information about you for treatment, to obtain payment for treatment (with your authorization as required by state laws), for administrative purposes, and to evaluate the quality of care that you receive.
ANTARES WELLNESS PLLC will not disclose your information to others unless you explicitly request it or unless the law requires and authorizes ANTARES WELLNESS PLLC to do so. ANTARES WELLNESS PLLC may use your information for appointment reminders, practice information, and other health-‐ related issues. If you believe your privacy rights have been violated, you may complain to the owner, Lashanna Williams, LMP, and to the Department of Health and Human Services. There will be no retaliation made against you for filing a complaint. ANTARES WELLNESS PLLC must maintain the privacy of protected health information; provide you with notice of its legal duties and privacy practices with respect to your health information; abide by the terms of the notice, notifying you if unable to agree to the requested restriction on how your information is used or disclosed; accommodate reasonable requests you may make to communicate health information by alternate means; and obtain your written authorization to use or disclose your health information for reasons other than those listed above and permitted by law.
If you have any questions or concerns, please contact Lashanna Williams.
Patient Signature / Personal Representative Signature
Personal Representative Name and Role
Notice of Privacy Practices
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
Your Rights and Choices
You have the right to: • Get a copy of your paper or electronic medical record • You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this. We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-‐based fee. • Correct your paper or electronic medical record • You can ask us to correct health information about you that you think is incorrect or incomplete. • We may say “no” to your request, but we’ll tell you why in writing within 60 days. • Request confidential communication • You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. • We will say “yes” to all reasonable requests. • Ask us to limit the information we share • You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care. • If you pay for a service or health care item out-‐of-‐pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information. • Get a list of those with whom we’ve shared your information • You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why. • We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-‐ based fee if you ask for another one within 12 months. • Get a copy of this privacy notice • You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly. • Choose someone to act for you • If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. • We will make sure the person has this authority and can act for you before we take any action. • File a complaint if you believe your privacy rights have been violated • You can complain if you feel we have violated your rights by contacting us using the information on page 1. • You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1877-6966-775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/. • We will not retaliate against you for filing a complaint.
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.
In these cases, you have both the right and choice to tell us to: • Share information with your family, close friends, or others involved in your care • Share information in a disaster relief situation. If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
In these cases we never share your information unless you give us written permission: • Marketing purposes • Sale of your information • Most sharing of psychotherapy notes. In the case of fundraising: • We may contact you for fundraising efforts, but you can tell us not to contact you again.
Our Uses and Disclosures
How do we typically use or share your health information? We typically use or share your health information in the following ways. • To treat you • We can use your health information and share it with other professionals who are treating you. • Run our organization: We can use and share your health information to run our practice, improve your care, and contact you when necessary. • Bill for your services We can use and share your health information to bill and get payment from health plans or other entities.
How else can we use or share your health information?
We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
Help with public health and safety issues
We can share health information about you for certain situations such as: • Preventing disease • Helping with product recalls • Reporting adverse reactions to medications • Reporting suspected abuse, neglect, or domestic violence • Preventing or reducing a serious threat to anyone’s health or safety • Do research: We can use or share your information for health research. Comply with the law. We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law. Work with a medical examiner or funeral director
We can share health information with a coroner, medical examiner, or funeral director when an individual dies. Address workers’ compensation, law enforcement, and other government requests.
We can use or share health information about you: • For workers’ compensation claims • For law enforcement purposes or with a law enforcement official • With health oversight agencies for activities authorized by law • For special government functions such as military, national security, and presidential protective services
Respond to lawsuits and legal actions: We can share health information about you in response to a court or administrative order, or in response to a subpoena.
Our Responsibilities • We are required by law to maintain the privacy and security of your protected health information. • We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. • We must follow the duties and privacy practices described in this notice and give you a copy of it. • We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html. Changes to the Terms of this Notice. We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.