I voluntarily consent to participate in an informational and educational health assessment, which may include non-invasive health screening, health and well-being coaching, and/or educational wellness consulting.
I understand that these services are non-diagnostic, are provided for educational and informational purposes only, and do not constitute medical advice, diagnosis, or treatment, nor do they replace care from my personal healthcare provider.
I understand that by completing and submitting this form, I may provide protected health information (PHI). When applicable and at my request, this information may be shared with HIPAA-covered entities, such as a healthcare provider or laboratory, for purposes related to evaluation, treatment, payment, and healthcare operations.
I authorize the use and disclosure of my PHI consistent with applicable law and for the purposes described above, including contacting me regarding services, results, or related educational follow-up. I understand that this authorization is voluntary and that I may revoke it at any time in writing, except to the extent that action has already been taken in reliance on it. I acknowledge that I have been offered access to the organization’s Privacy Policy, which includes the HIPAA Notice of Privacy Practices (NPP).
