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.
Effective on the date submitted,Between:Peak Performance & Prevention317 4th ST NWPuyallup, WA 98371
This P3 Membership Agreement (the “Agreement”) is comprised of the attached (i) Membership Form, (ii) Terms of Service, (iii) Disclosure Statements, and (iv) Service Scope and Additional Service Form located at P3life.com, which is incorporated herein by reference, and constitutes a binding commitment between P3 and Member, effective upon the Effective Date, and supersedes all prior written or verbal agreements or understandings. Member acknowledges that Member has received reference to, read, and understands the Agreement, and agrees to all such terms and conditions of the foregoing documents, together with applicable policies. Should You be dissatisfied with your care or service, P3 requests you contact us immediately so we may attempt to resolve your complaint satisfactorily. Unresolved complaints may be brought to the attention of the Office of the Insurance Commissioner for the State of Washington by calling the Consumer Advocacy Department at (800) 562-6900 or by emailing firstname.lastname@example.org.
1. Membership Term. Membership term is month to month, commencing on the Effective Date and continuing until termination pursuant to this Agreement.
2. Scope of Member Services. The scope of the services included with the Membership, and any additional services that Member may purchase at additional cost, are set forth in the Service Scope and Additional Service Form located at https://p3life.com/plans. P3 may modify the Service Scope and Additional Service Form from time to time, provided there is no substantial change in the level of services provided. In such event, P3 will notify You thirty (30) days prior to such modifications going into effect.
3. Membership Fees. Members are responsible for the following fees in connection with the Membership: i. One-time, non-refundable Enrollment Fee – $175.00
ii. Member Fee [recurring monthly] – $125.00
iii. Member Fee Plus Amortized Labs [recurring monthly]- $200.00
DISCLOSURE STATEMENTSP3 makes the following disclosure statements:
i. You are voluntarily becoming a member of P3 as a patient.
ii. You understand that P3 is a primary care practice and is NOT an insurance company. P3 encourages You to obtain and maintain insurance for services not provided by this direct Membership Agreement.
ii. P3 does not bill insurance carriers for any services provided by P3 and will not be responsible to assist with insurance submittals.
iii. P3 does not provide or pay for medical services other than those specified in this Membership Agreement.
iv. P3 will provide You with data regarding payments made and services rendered to You upon request.
vi. Late payment fees may apply for failure to pay the monthly Member fee on or before the due date.
vii. You have the right to terminate the Agreement at any time for any reason by providing written notice to P3. Any pre-paid monthly fees will be prorated to the date P3 received written notice of termination.
viii. P3 may add or discontinue service or may increase your Membership Fee at any time (but not more than once per calendar year) upon sixty (60) days advance written notice.
ix. You, as a Member, are entitled to care without discrimination.
MEMBER ACCEPTANCE: By signing below, member acknowledges that they have reviewed the entire agreement and agrees to be bound hereby.