P3's 5 Pillar's of Health:
Sleep. Movement. Nutrition. Connection. Detoxification.
We Do Not Pursue Perfection but Excellence
This is to acknowledge that I have been informed and understand that:1. Any treatment or advice provided to me as a patient of Peak Performance & Prevention is not mutually exclusive from any other treatment or advice that I may be receiving now or in the future, from another healthcare provider.2. I am at liberty to seek or continue medical care from a physician, surgeon, or other healthcare provider.3. No physician, healthcare provider, or staff member at the office of Peak Performance & Prevention is recommending that I refrain from seeking or following the advice of another licenesed healthcare provider.4. Recommended therapies provided by this clinic may be different from those usually offered by another licensed healthcare provider.5. I hereby authorize and consent to treatment.
The privacy of your medical information, as described in the HIPPA Privacy Act, is important to us. We understand that your medical information is personal and we are committed to protecting it. We create a record of the care and services you receive at our organization. We need this record to provide you with quality care and to comply with certain legal requirements. We will not use or disclose your medical information for any purpose not listed below, without your specific written authorization. Any specific written authorization you provide may be revoked at any time by writing to us at the address provided at the end of this notice. We may use medical information about you to doctors, nurses, technicians, medical students or other health care providers to assist them in treating you. We may use and disclose your medical information for payment purposes. A bill may be sent to you or a third-party payer. The information on or accompanying the bill may include your medical information.
Respectfully, Peak Performance & Prevention
I understand that I may cancel this consent at any time, by writing to the P3 manager, but that cancelling will not affect information that has already been released.
I understand that I do not have to sign this form and that I should only sign if I want my medical provider or my clinic to share my information with someone.
This authorization expires: when I cancel it in writing, or one (1) year from the date signed.