Table of Contents - Pritikin Longevity Center & Spa · 2017. 3. 17. · 8755 NW 36 th Street •...

Table of Contents

Required Forms

Page 1 Page 2-4 Page 5-11P age 12

ETT Consent Form General Consent Form HIPAA Privacy Notice & Authorization for Release of Health Information Pursuant to HIPAA Medical Records Release Form

Optional Forms

Page 13-15 Bone DXA Patient Questionnaire Page 16 Disclosure Request for Protected Health Information Page 17-18 Minor Consent and Release Form

8755 NW 36th Street • Miami, FL 33178 • Tel: 305.935.7141 • Fax: 305.935.5018 www.pritikin.com


ETT CONSENT FORM

I, ___________________________ authorize Dr. Seth Marquit, Medical Director, representing

Florida Pritikin Center, LLC, and/or such staff or assistants as Dr. Seth Marquit may

designate to administer one or more Graded Exercise Tolerance Tests (abbreviated as

ETT) at Pritikin Longevity Center & Spa using a motor-driven treadmill or an exercise

bicycle or a Nu-Step exercise machine.

The ETT is designed to determine an individualized level of exercise that I can both

safely and effectively participate in. I understand that the ETT will require that I walk on

a motor-driven treadmill or pedal an exercise bicycle or Nu-Step machine. During the

ETT my electrocardiogram will be recorded continuously, my blood pressure recorded

at intervals and the exercise progressively increased to the point of fatigue or to a

predetermined end point. I acknowledge that I have the right and ability to terminate

the ETT at any time.

I understand that with this ETT there is a risk of unexpected, abnormal changes

occurring in the cardiovascular system during or following the ETT. These changes may

include abnormalities of blood pressure (high or low), lightheadedness, fainting,

shortness of breath, chest tightness or chest pain, palpitations or changes in heart

rhythm, leg cramps or muscle pain. In rare instances, “heart attacks” or cessation of

heart function can occur. Emergency equipment and personnel trained in CPR are

immediately available to deal with and to minimize the danger of

unexpected cardiovascular events should they occur. I understand these risks and

authorize the administration of one or more ETTs.

I have read the foregoing information, and I understand it completely. All questions

concerning the risk of an ETT have been answered to my satisfaction.

_____________________________

Print Name

_____________________________ Dated: ________________________

Sign Name

_____________________________ Dated: _________________________

Witness Signature

Questions for witness to ask signer:

1. Have you read this form completely? Yes No2. Do you understand this form?Yes No3. Do you have any questions about the content? Yes No

(MM/DD/YYYY)

(MM/DD/YYYY)


GENERAL CONSENT FORM

Patient Name: ______________________________ Date of Birth: ____/____/____

I voluntarily consent to and authorize the healthcare providers of Pritikin Longevity

Center and Spa (“Pritikin”), including physicians, midlevel providers (including but not

limited to Physician Assistants, Nurse Practitioners, Nutritionists, and Psychologists) nurses

paramedics, phlebotomists and medical assistants, as applicable, to provide health

care services to me as part of my participation in Pritikin’s programs. The health care

services may include, without limitation, routine physical and mental assessment,

nutritional analysis and recommendation, diagnostic and monitoring tests and

procedures, examinations and medical treatment, routine laboratory procedures and

tests (such as blood, urine and other studies), x-rays and other imaging studies, heart

tracing (EKG), administration of medications, as well as other procedures and

treatment prescribed by Pritikin’s medical staff.

My signature on this form indicates that:

1. I understand that no warranty or guarantee has been made to me with respect to

care to be provided.

2. I realize that there may be risks and hazards related to the performance of any

planned care for me.

3. I have been given an opportunity to ask questions about my condition, treatment

options, risk of treatment, risks of non-treatment, procedures to be used, and I believe

that I have sufficient information to give this informed consent.

4. I agree that Pritikin may provide the Privacy Notice required by HIPAA to me

electronically by posting the Privacy Notice to my electronic medical record where I will

review and acknowledge receipt of the Privacy Notice by logging into the Pritikin web

site portal. I understand that I have the right to receive the Privacy Notice in paper

format.

5. I certify that this form has been fully explained to me, that I have read it or have had

it read to me, that any blank spaces have been filled in, and that I understand its

contents.

6. I understand that this Consent Form is voluntary and that I may refuse to sign it.

7. I acknowledge that I have carefully read and understand the information presented

to me and in this informed Consent Form.

8. I understand that I may be asked to sign a separate informed consent form for

certain treatments that require a separate informed consent form.

9. I release Pritikin from responsibilities and liabilities while I am away from the Pritikin

center for any reason, including hospital-based procedures.

(MM/DD/YYYY)


I consent to, and agree with the preceding statements.

By:_____________________________________ Date:__________________

[Signature of Patient]

Or,

By:____________________________________ Date:____________________

[Signature of Legal Representative]

Print Name:______________________________________________________

[Relationship to Patient] ____________________________________________

Translator to complete when applicable:

I have accurately and completely read the foregoing document to the above named

patient in ________________________, the Patient’s or the Legal Representative’s

primary language. S/He understood all of the terms and conditions and acknowledged

his/her agreement and consent thereto by signing the document in my presence.

Translated By:____________________________ Date:____________________

[Signature of Translator]

Print Name:_______________________________________________________

Witnessed by:_____________________________________________________

[Signature of Witness]

Print Name:______________________________ Date:____________________

(MM/DD/YYYY)

(MM/DD/YYYY)

(MM/DD/YYYY)

(MM/DD/YYYY)


HIPAA PRIVACY NOTICE Effective September 23, 2013

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.

Uses and Disclosures of Protected Health Information

Under the Health Insurance Portability and Accountability Act of 1996

(“HIPAA”),1 Florida Pritikin Center, LLC is required by law to protect the privacy of your

individually identifiable health information (referred to here as “protected health

information” or “PHI”) and to provide you with notice of its legal duties and privacy

practices with respect to PHI. Florida Pritikin Center, LLC is required to abide by the

terms of the notice currently in effect, and will retain a copy of the notice in Florida

Pritikin Center, LLC’s office.

HIPAA permits Florida Pritikin Center, LLC to make certain types of uses and

disclosures of PHI without your authorization for treatment, payment and healthcare

operations purposes:

For treatment purposes, such use and disclosure will take

place in providing, coordinating or managing healthcare and its related services by

one or more of your providers, such as when your primary care physician consults with a

Florida Pritikin Center, LLC provider regarding your condition. Florida Pritikin Center, LLC

may make such uses and disclosures without your authorization;

For payment purposes, such use and disclosure will take place to obtain premiums, or in

appeals of denied claims, or to determine responsibility for coverage and benefits, such

as if Florida Pritikin Center, LLC confers with insurers to resolve a coordination of benefits

issue or to obtain or provide reimbursement for providing health care, such as when

your case is reviewed to ensure that appropriate care was rendered.

1 The Health Insurance Portability and Accountability Act of 1996 (commonly known as “HIPAA”), Pub. L.

No. 104-191, and its implementing regulations at 45 C.F.R. Parts 160 and 164 (“Privacy Rule”), govern the use

and disclosure of an individual’s protected health information.


For healthcare operations purposes, such use and disclosure will take place in a

number of ways, including for quality assessment and improvement, provider review

and training, underwriting activities, reviews and compliance

activities, planning and development, management and Florida Pritikin Center, LLC

administration. Your information could be used, for example, to assist in the

evaluation of the quality of care that you were provided.

In addition, Florida Pritikin Center, LLC may:

Contact you to provide information about other health-related benefits and services

that may be of interest to you. We may also release demographic information about

you for fundraising purposes to the Pritikin Foundation including your name, address,

phone number, age, gender, insurance status, and dates of service. We will not release

information regarding your illnesses or treatments. If you do not want to receive direct

solicitations regarding current fundraising efforts from the Pritikin

Foundation, you have the right to opt out of receiving such communications.

Florida Pritikin Center, LLC may use and disclose your PHI, without your

authorization, as follows:

as required by law;

for public health activities;

to report victims of abuse, neglect or domestic violence;

for health oversight activities;

for judicial and administrative proceedings;

for law enforcement purposes and to report a crime;

to permit authorized organ donations;

for valid research purposes;

for Workers’ Compensation;

to avert a serious threat to health or safety; and

for a specialized government function involving the military and veterans

activities, national security, protective services for the President, correctional

facilities, law enforcement custodial situations, and government programs

providing public benefits.

Anyone requesting a disclosure of your PHI in the absence of your specific authorization

will be required to provide reasonable proof to Florida Pritikin Center, LLC that the

requested disclosure is for one of these permitted purposes under the law.

Under HIPAA, there are some uses and disclosures that specifically require your

authorization, including uses and disclosures that relate to psychotherapy notes,


marketing activity and the sale of your protected health information. Other uses and

disclosures not described in this HIPAA Privacy Notice will be made only with your

written authorization.

Florida Pritikin Center, LLC does not contemplate that there will be routine situations

where persons you have not authorized will present themselves as persons involved in

your healthcare to request your PHI from Florida Pritikin Center, LLC, and will only

respond to such questions from dependents that are authorized by you, the individual

who is subject to the PHI. If you are incapacitated, there is an emergency or you

otherwise do not have the opportunity to object to this use or disclosure, Florida

Pritikin Center, LLC will do what in its judgment is in your best interest regarding such

disclosure and will disclose only the information that is directly relevant to the person's

involvement with your healthcare. Florida Pritikin Center, LLC will use its reasonable

judgment and only respond to basic questions about coverage and eligibility and

appeals made on your behalf by persons involved in your healthcare if you specifically

authorize Florida Pritikin Center, LLC in writing to provide such information.

Florida Pritikin Center, LLC cannot recognize a person as a personal

representative if:

The covered individual is an unemancipated minor receiving a healthcare service the

law permits the minor to consent to receive and the minor has not designated a

personal representative;

The minor may lawfully obtain the service without parental

Consent2 and a lawful consent has been obtained;

The parent has agreed to confidentiality between the minor and Florida Pritikin Center,

LLC;

______________

2 The term “parent” includes a legal guardian or other person acting in the place of the

parent under the laws of the State of Florida.

Florida Pritikin Center, LLC has a reasonable belief that the individual has been or may

be subject to domestic violence or may otherwise be endangered; or

Florida Pritikin Center, LLC determines recognizing the personal representative is not in

the individual’s best interest.


Additional Rights under HIPAA

You have the right to request the following with respect to your PHI:

(i) inspection and copying (see 45 C.F.R. § 164.522); (ii) amendment (which can be

denied) or correction (see 45 C.F.R. § 164.526); (iii) an accounting of certain disclosures

of PHI by Florida Pritikin Center, LLC (see 45 C.F.R. § 164.528)3; (iv) confidential

communications; and (v) the right to receive a paper copy of Florida Pritikin

Center, LLC’s Privacy Notice upon request. You must write to Florida Pritikin Center,

LLC’s HIPAA Privacy Officer describing in detail the specific items requested, namely:

(i), (ii) and/or (iii), above. Florida Pritikin Center, LLC may charge a reasonable fee both

for additional accountings beyond one per year, and for copying and mailing PHI.

Florida Pritikin Center, LLC does not charge patients for copying and mailing PHI, but

Florida Pritikin Center, LLC assesses the copying charges permitted by Florida law with

respect to all other entities.

You may revoke your authorization unless Florida Pritikin Center, LLC has already

disclosed your PHI pursuant to your authorization by notifying Florida Pritikin

Center, LLC. You may ask Florida Pritikin Center, LLC to restrict uses and disclosures of

your PHI to carry out treatment, payment or health care operations, or to restrict uses

and disclosures to family members, relatives, friends or other persons identified by you

who are involved in your care or payment for your care (see 45 C.F.R. § 164.522).

However, Florida Pritikin Center, LLC is not required to agree with your request except if

you have paid in full for all services provided by Florida Pritikin Center, LLC. If you have

paid in full for all services provided by Florida Pritikin Center, LLC you may request that

Florida Pritikin Center, LLC restrict disclosures to a health plan and Florida Pritikin

Center, LLC may not deny your request unless the disclosure is required by law. If you

utilize a flexible spending account, a medical expense reimbursement account or a

health savings account to pay for treatment, you may not restrict disclosure to such

flexible spending account, medical expense reimbursement account or health savings

account.

You have the right to be notified if the privacy and security of your PHI has been

compromised and is considered to meet the definition of a “breach” under HIPAA.

Florida Pritikin Center, LLC reserves the right to change the terms of this Privacy Notice

and to make the new Privacy Notice effective for all PHI Florida Pritikin

Center maintains.

3 Pritikin Longevity Center + Spa is not required to, and will not, account for disclosures

made for treatment, payment or healthcare operations, for national security, to law

enforcement, to corrections personnel, pursuant to your authorization, or to you, unless

specifically required by law.


Revisions to the terms of the Privacy Notice will be sent to you by United

States mail.

If you believe that your privacy rights have been violated by Florida Pritikin Center, LLC,

you may complain in writing to Florida Pritikin Center, LLC by sending a letter addressed

to the HIPAA Privacy Officer at address below, or to the Secretary of the Department of

Health and Human Services. You will not be retaliated against for filing a complaint.

Contacting Florida Pritikin Center, LLC

For further information regarding HIPAA, you may contact Florida Pritikin Center, LLC as

follows:

Lida MirbagheryHIPAA Privacy Officer

Florida Pritikin Center, LLC

8755 NW 36th Street

(305)-935-7131

Miami, Florida 33178

Acknowledgment of Receipt of Florida Pritikin Center, LLC’s

HIPAA Privacy Notice

By signing this document, I acknowledge that I have received a copy of Florida Pritikin

Center, LLC’s HIPAA Privacy Notice.

________________________

Name (Print)

________________________

Signature

Or

Reason acknowledgment was not obtained:______________________________________

_____________________________________________________________________________________

________________________

Date (MM/DD/YYYY)

Florida Pritikin Center, LLC’s Use Only Below This Line:

____________________________________________________________________________________

Date acknowledgment received:________________ (MM/DD/YYYY)

jweinberg

Sticky Note

Unmarked set by jweinberg


Authorization for Release of Health Information Pursuant to HIPAA


Patient Address:________________________________________________________

I, or my authorized representative, request that health information regarding my care

and treatment as set forth on this form:

In accordance with the Health Insurance Portability and Accountability Act of 1996

(HIPAA), I understand that:

1. This authorization may include disclosure of information relating to ALCOHOL and

DRUG ABUSE, MENTAL HEALTH TREATMENT, except psychotherapy notes, and

CONFIDENTIAL HIV* RELATED INFORMATION only if I place my initials on the appropriate

line in Item 9(a). In the event the health information described below includes any of

these types of information, and I initial the line on the box in Item 9(a), I specifically

authorize release of such information to the person(s) indicated in Item 8.

2. If I am authorizing the release of HIV-related, alcohol, or drug treatment, or mental

health treatment information, the recipient is prohibited from redisclosing such

information without my authorization unless permitted to do so under federal or state

law. I understand that I have the right to request a list of people who may receive or

use my HIV-related information without authorization.

3. I have the right to revoke this authorization at any time by writing to the health care

provider listed below. I understand that I may revoke this authorization except to the

extent that action has already been taken based on this authorization.

4. I understand that signing this authorization is voluntary. My treatment, payment,

enrollment in a health plan, or eligibility for benefits will not be conditioned upon my

authorization of this disclosure.

5. Information disclosed under this authorization might be redisclosed by the recipient

(except as noted above in Item 2), and this redisclosure may no longer be protected

by federal or state law.

6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATIONOR MEDICAL CARE WITH ANYONE OTHER THAN THE ENTITY SPECIFIED IN ITEM 8(b).

(MM/DD/YYYY)


7. Name and address of person(s) or category of person to whom this information will

be provided:

Florida Pritikin Center, LLC

8755 NW 36th Street

Miami, Florida 33178

8(a). Specific information to be released:

□ Medical Record from (insert date)____________ to (insert date)__________

□ Entire Medical Record, including patient histories, office notes (except

psychotherapy notes), test results, radiology studies, films, referrals, consults, billing

records, insurance records, and records sent to you by other health care providers.

□ Other: _________________________________________________________________

Include: (Indicate by Initialing)

_________ Alcohol/Drug Treatment

_________ Mental Health Information

_________ HIV-Related Information

Authorization to Discuss and Disclose Health Information

(b). I authorize any medical service provider who consults with me or provides care to

me while I am a patient of Florida Pritikin Center, LLC to disclose and discuss my health

information with Florida Pritikin Center, LLC.

9. Date or event on which this authorization will expire:______________________________

10. If not the patient, name of person signing form:___________________________________

_____________________________________________________Date:_____________

Signature of Patient or representative

* Human Immunodeficiency Virus that causes AIDS.

(MM/DD/YYYY)

(MM/DD/YYYY)


Medical Records Release Form


Patient Address:________________________________________________________

City:_______________________State:____________Zip Code:__________________

Phone Number:_______________________________Email Address____________

Florida Pritikin Center, LLC (FPC) will transmit copies of your medical records to the

Pritikin Patient Portal where they will be stored and you can view or print them. An

invitation to create an account in the Pritikin Patient Portal will be sent to your email

address listed above.

Florida Pritikin Center, LLC will not share your email address with any other person(s) or

agencies without your express, written consent.

Florida Pritikin Center, LLC (FPC) can also send medical records to you by mail. You

should understand that Florida Pritikin Center, LLC cannot be held responsible for

mailed records that do not reach your address. You should understand that mail

communication is not a secure means of transmission.

____ Authorization to mail records by U.S. Postal Service to the address listed above.

_____ I Decline the transmission of my Medical Records.

Signature: __________________________ Date: ___________________

(MM/DD/YYYY)

(MM/DD/YYYY)

____ Authorization to receive electronic medical records (Portal). Access to electronic medical records requires last 4 of your Social Security number ( SSN), or enter "1111" if you are from a country that does not use Social Security.Last 4 of SSN _______

Please initial your option below:


BONE DXA PATIENT QUESTIONNAIRE

Today’s Date: ______________________

Ethnicity: _________________________

Pritikin Physician: __________________

Current Height (in.): ________________

Country of Birth: ___________________

Forearm Length: ___________________

Name: __________________________

Sex: M______ F______

Date of Birth: ________________

Weight (lb.): _____________________

Menopause Age: __________________

Dominant Hand: __________________

Patient ID: _______________________ Medicare #: ________________________

1. Is there a chance that you are pregnant? YES NO

2. Have you had a barium X-ray in the last 2 weeks? YES NO

3. Have you had a nuclear medicine scan or injection

of an X-ray dye in the last week? YES NO

4. Have you taken a calcium supplement today? YES NO

If you answered yes to any of the above, speak to our receptionist right away.

5. Have you ever broken a bone? YES NO

Broken Bone Simple fall? If not a simple fall, please describe the

circumstances

Age when this

occurred

6. Have you ever been treated for osteoporosis? YES NO

7. Has a parent or sibling had a broken hip from a simple fall or bump? YES NO

8. Do you smoke? YES NO

For how many years and how much do you smoke? _______________________

9. Have you taken glucocorticoids (i.e. 5mg of predinisone daily

for more than 3 months)? YES NO

10. Have you ever been diagnosed with rheumatoid arthritis? YES NO

11. Have you ever been treated for secondary osteoporosis? YES NO

(i.e. type 1 diabetes, osteogenesis imperfecta, untreated hyperthyroidism,

hypogonadism, premature menopause, malnutrition, malabsorbtion, chronic

liver disease)

12. Do you drink 3 or more units of alcohol per day? YES NO

(A unit is defined as 8-10g of alcohol which is the equivalent to a standard

glass of beer, a single measure of spirits or a medium-sized glass of wine)

13. Is there any metal or plastic in your body? YES NO

If YES, where? _____________________

14. Have you ever had a bone density or body composition test? YES NO

If YES, when and where? ___________________________

15. Do you perform weight-bearing exercise regularly? YES NO

16. Do you drink caffeine-containing beverages? YES NO

How many ounces of caffeinated beverages do you consume daily? __________

(MM/DD/YYYY)

(MM/DD/YYYY)


17. Do you take any vitamin D supplements (including multivitamins)? YES NO

How much do you take? _________________

18. How many servings of the following do you eat/drink per day (on average)?

Milk or Soy milk

(1 cup)

Orange juice fortified

with calcium (1 cup)

Yogurt (1 cup) Cheese (1

ounce)

Number of

servings

19. What was your maximum height in inches (assuming you are not as tall as you once were)?

_______

20. Has a parent or sibling had any other type of broken bone from

a simple fall or bump? YES NO

21. How many times have you fallen in the last year? __________

22. Have you ever had surgery of the spine, hips, legs or arms? YES NO

23. Are you currently receiving or have you previously received predisone pills (cortisone)?

Yes, currently _______ Yes, previously _______ No _______

If YES, for how long? _______ What is your dose? _______mg or _______ pills per day

24. Are you currently receiving or have you previously received any of the following

medications?

No Yes For how long?

Medication for seizures or epilepsy

Chemotherapy for cancer

Medication for prostate cancer

Medication to prevent organ transplant rejection

Medication for gastric reflux disease

25. Have you ever been treated with any of the following medications?

Medication Ever? Currently? If current, how long?

Hormone replacement therapy (Estrogen)

Tamoxifen or Raloxifene (Evista)

Actos

Testosterone

Etidronate (Didronel/Didrocal)

Alendronate (Fosamax)

Risedronate (Actonel)

Intravenous pamidronate (Aredia)

Clodronate (Bonefos, Ostac)

Calcitonin (Miacalcin nasal spray

Parathyroid Hormone (Forteo)

Zoleddronic acid (Zometa)

Lupron injections

Boniva (i.e. ibandronate)

Prolia (Denosumab)

Ergocalciferol (Vitamin D2)


26. Do you have any of the following medical conditions?

__Anexoria or Bulimia __Seizures Disorders

__Asthma or Emphysema __Cancer

__End stage renal disease __Hyperparathyroidism (high calcium)

__Vitamin D deficiency __Rheumatoid arthritis

__Inflammatory bowel diseases (e.g. Ulcerative Colitis, Crohn’s disease)

__Other – Please specify: ____________________________________

For women only…

27. At what age id your period start? _________

How many full term pregnancies have you had? ________

28. Have you ever missed your period for more than 6 months in a row YES NO

(not including pregnancy or menopause)?

29. Have you had your menopause? YES NO

If yes, at what age? _________

30. Have you had a hysterectomy? YES NO

If YES, at what age? ________

31. Have you had both of your ovaries removed? YES NO

If YES, at what age? ________

Patient signature_________________ Date______________ (MM/DD/YYYY)


DISCLOSURE REQUEST FOR PROTECTED HEALTH INFORMATION


Patient Address:________________________________________________________

City:____________________________State:________Zip Code:________________

Phone Number:_______________________________MR#:____________________

SS#:___________________________________________________________________

To be completed by requester (circle one): Pick Up Mail If requested health information is needed for a doctor’s appointment please specify date:

Date(s) of Service: _____________________________________________________

Reason for requesting information (circle one): Personal Legal Insurance Requests may be subject to copying fee

I agree that this information may be mailed to and used by the following individual or organization:

Name:

Address: City: _______________________________________ State: ____________ Zip Code:________

I understand that authorizing the disclosure of this health information is voluntary. I understand that I may inspect or obtain a copy of the information to be disclosed, as provided in CFR 164.524. I understand that any disclosure of information carries with it the potential for an unauthorized re-disclosure and the information may not be protected by Federal confidentiality rules. If I have questions about disclosure of my health information, I will contact Florida Pritikin Center, LLC.

I understand the information in my health record may include psychiatric, alcohol or drug abuse/testing information which may be protected by Federal and State Regulations. I also understand that my health record may include information relating to AIDS, HIV, and/or sexually transmitted disease.

Patient Signature: _______________________________________________ Date: _______

Authorized Representative/Parent: ______________________________ Date: _______

Printed Name of Authorized Representative/Parent:______________________________________________________________

Relationship to Patient: ______________________________________________________________Phone # of Authorized Representative/Parent: _______________________________________Address of Authorized Representative/Parentent: ___________________________________________________________________________________________________________________________

(MM/DD/YYYY)

(MM/DD/YYYY)

(MM/DD/YYYY)

(MM/DD/YYYY)


MINOR RELEASE AND CONSENT FORM General Release As the parent/legal guardian of _______________________________________(the “CHILD”), I

assume the risk with respect to the CHILD’s visit to Florida Pritikin Center, LLC (“Pritikin”). I

release all rights and claims for damages which the CHILD and the CHILD’s heirs,

executors, and administrators, or I may have against Pritikin, its employees, directors,

officers, consultants, agents, members, contractors or representatives for injuries or

damages that occur as a result of the CHILD’s visit to Pritikin.

Consent I voluntarily consent to and authorize the healthcare providers of Pritikin, including

physicians, midlevel providers (including but not limited to Physician Assistants, Exercise

Physiologists, Nutritionists, and Psychologists) paramedics and nurses, as applicable, to

provide health care services to the CHILD as part of participation in Pritikin’s programs.

The health care services may include, without limitation, routine physical and mental

assessment, nutritional analysis and recommendation, diagnostic and monitoring tests

and procedures, examinations and medical treatment, routine laboratory procedures

and tests (such as blood, urine and other studies), x-rays and other imaging studies,

heart tracing (EKG), administration of medications, as well as other procedures and

treatment prescribed by Pritikin’s medical staff. I understand that no warranty or

guarantee has been made to me with respect to care to be provided. I realize that

there may be risks and hazards related to the performance of any planned care for the

CHILD. I have been given an opportunity to ask questions about the CHILD’s condition,

treatment options, risk of treatment, risks of non-treatment, procedures to be used, and I

believe that I have sufficient information to give this informed consent. I certify that this

form has been fully explained to me, that I have read it or have had it read to me, that

any blank spaces have been filled in, and that I understand its contents. I understand

that signing this Minor Release and Consent form is voluntary and that I may refuse to

sign it. However, I understand that if I do not sign this Minor Release and Consent form,

that the CHILD may not be permitted on Pritikin’s premises. I acknowledge that I have

carefully read and understand the information presented to me. I understand that I

may be asked to sign a separate informed consent form for certain treatments that

require a separate informed consent form. I release Pritikin from responsibilities and

liabilities while the CHILD is away from the Pritikin premises for any reason, including

hospital based procedures. I hereby give my consent for the CHILD to be treated by

and admitted to any hospital or medical facility for diagnosis and treatment if

necessary. I request and authorize physicians, nurses, dentists and other medical staff

from that hospital or medical facility to perform any diagnostic, treatment, and/or

operative health care procedures that are medically necessary to the CHILD.


Page 2 of 2

NAME: DATE:

I hereby accept financial responsibility for any and all medically necessary treatment

administered to the CHILD in the event of an accident, injury, sickness, etc. to the same

extent as if I had personally contracted for such care and services and agree to pay all

such charges.

These powers shall be effectively immediately and shall not terminate unless revoked by

me in writing with notice to all interested parties.

HIPAA Authorization Pursuant to the Health Insurance Portability and Accountability Act of 1996 (HIPAA), as

the parent/legal guardian of the CHILD, I am the CHILD’s personal representative. In

that capacity,

I appoint and designate ____________________________________________(the “Guardian”)

as the CHILD’s personal representative during the CHILD’s visit to Pritikin. The Guardian

shall have the status, power, authority and rights as the CHILD’s personal representative

for all purposes as provided under HIPAA.

Medical Information The CHILD’s date of birth _____/_____/_____

The following is a list of known allergies and allergies to medications of the

CHILD:________________________________________________________________

The CHILD has the following known medical

conditions:__________________________________________________________________________

_________________________________________________________

The CHILD will be bringing the following prescriptions or

medications:___________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Background Information Family Physician:____________________________ Phone Number:____________________

Names of Parents/Guardian:____________________________________________________

Address: City/State/Zip:________________________________________________________

Phone: (H)____________________ (W)_____________________(Other)_________________

Insurance Company:___________________________________________________________

Policy or Group Number:________________________________________________________

Signature of Parent/Guardian:_______________________________________Date:_________

(MM/DD/YYYY)

_____________________________________________

______________

(MM/DD/YYYY)

(MM/DD/YYYY)

Date post:	17-Aug-2020
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