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General Patient Intake Form

Visit & Patient Information


Visit & Patient Information

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Personal Information
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Contact Information
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Insurance Information
Please attach a copy of your insurance card (front & back) (If you do NOT have medical insurance, please fill in N/A in each of the insurance fields).
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Waiver & Release of Liability


Waiver & Release of Liability

The undersigned is a client, employee, independent contractor, visitor or guest of CONNECTED HEALTH, LLC, CONNECTED HEALTH MEDICAL SERVICES, LLC, ATHLETIC REPUBLIC PITTSBURGH, (“Connected Health”), PERFORMANCE UNLIMITED or OTHER INDEPENDENT CONTRACTOR of Connected Health (collectively “CH”). In consideration for the undersigned’s employment, contractor status, access to or use of CH equipment or services related to personal training, group exercise, Athletic Republic, nutrition consultation or advice, massage therapy and bodywork, physical therapy or other health and wellness services (collectively, the “Services”), the undersigned understands that access to or use of Services at the CH facility located at 12620 Perry Highway Wexford, PA 15090 (the “Facility”) or Services provided by CH at the undersigned’s home and/or place of business is conditioned upon his or her execution of this Waiver and Release of Liability.
THIS DOCUMENT IS A WAIVER AND RELEASE OF LIABILITY which means by signing it I am waiving and releasing all legal rights (held by myself, and on behalf of my heirs, assigns, personal representatives and next of kin) to claim, sue or attempt to hold liable the parties being released as to any illness or hardship related to the COVID-19 pandemic or other pandemic (“Event”), general illness or disease, injury, death or property damage sustained in connection with my limited right to utilize the Services. Intended to be legally bound hereby, I voluntarily, knowingly, completely and forever release, waive and discharge CH and all of their affiliated companies (collectively, the “Released Parties”), from any and all claims, actions, costs, losses, expenses, demands, damages or other liabilities, known or unknown, absolute or contingent, and whether or not fixed, which I ever had, now have or might in the future have against any Released Parties, resulting in any manner from my access to or use of the Services. Without limiting the generality hereof, this release covers claims for personal and emotional injuries, property damage, claims for attorneys’ fees and costs, claims for liquidated damages, compensatory, general and punitive damages, and every other kind of relief available at law or in equity, whether accrued now or hereafter.
By signing below, I hereby release and discharge the Released Parties from any and all claims which may arise from any cause whatsoever in connection with my participation in the Services whether they be in person or virtual. I further release the Released Parties from any liability for any accident, illness, injury, death, loss or damage to personal property, or any other consequences arising or resulting directly or indirectly from my participation in the Services, whether they be in person or virtual. I acknowledge the Released Parties assume no responsibility for any liability, damage, injury or death that may be caused by my negligent or intentional acts or omissions committed prior to, during, or after participation in the Services, whether they be in person or virtual or for any liability, damage, injury or death caused by the intentional or negligent acts or omissions of others. I agree to indemnify, defend, and hold harmless the Released Parties from any injury, loss or liability including reasonable attorneys’ fees and/or any other associated costs, from any action, claim, or demand in connection with my participation in the Services whether they be in person or virtual.
By signing this Waiver and Release of Liability, I hereby assume all risks and dangers (whether known, unknown or hereafter discovered, anticipated or unexpected, real or imaginary, contingent or otherwise) and all responsibility for any losses and/or damages, whether cause in whole or in part by the conduct or omission (including all negligent acts and omissions) of any of the Released Parties.
I hereby further agree to indemnify, hold harmless, and defend the Released Parties, from and against any and all claims, losses, costs, damages, liabilities or expenses of any nature whatsoever (including attorney’s fees) arising out of or relating to the Services. My duty to indemnify, hold harmless, and defend the Released Parties shall survive the conclusion of my access to or use of the Services.
I acknowledge and agree that (i) due to the Event, my employment, contractor status, access to Services or use of Services may include certain protocols that I must abide by while in the facility including but not limited to restricted access to certain parts of the Facility or Services all of which may be adjusted on a daily basis in the sole and absolute discretion of the Released Parties, (ii) Facility amenities may no longer be available to me or may be interrupted as a direct or indirect result of the Event, including but not limited to, facility access via fob, gallery seating, towel service, locker room supplies, Café services, shower facilities, (iii) the Released Parties will have no obligations to provide any replacement services or compensation whatsoever to me during the Event, and (iv) I will promptly vacate the Facility at the request of the Released Parties, if required for any reason in association with the Event.
I hereby declare that I am physically sound and suffering from no condition, impairment, disease or illness that would prevent or limit my use of the Services. I acknowledge I have been informed of the need for physician approval for my use of the Services and hereby represent that I can safely engage in physical and other activity and that I am able to use the Services on an unsupervised basis.
I further understand and agree that, if I voluntarily choose to use the services of Connected Health’s Nutritionist, that he/she is not a physician, that those services focus on wellness and prevention of illness through the use of nutritional therapies, education and motivation to adopt a healthy lifestyle and diet and do not include the treatment or diagnosis of a specific illness or disorder. If I suspect I need medical attention, I will consult with a physician. Additionally, while my use of prescription drugs and other medications may be discussed with the Nutritionist, only a physician may prescribe drugs to me and any change in my prescription or dosage is a decision that must be made in consultation with a physician.

Acknowledgement of Waiver & Release of Liability


Acknowledgement of Waiver & Release of Liability

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Overview of Privacy Policy & HIPAA


Overview of Privacy Policy & HIPAA

At Connected Health, we are committed to protecting the privacy of your medical information, health, treatment, or payment information that identifies you, as federal and state laws require. Below you will find Connected Health’s “Notice of Privacy Practices” which explains our approach to your privacy, your legal rights concerning your privacy, and how all of the people and services employed and offered by Connected Health must follow the notice. Please note that this is not a complete listing of how we use and share your health information. If you have a question about any of the information in this summary, you should review the full notice of privacy practices or ask Connected Health staff members for more information. Connected Health has the right to change this summary and the notice without first notifying you.
Why you are receiving this notice from Connected Health, as well as other providers? Your health care provider must provide you a notice that tells you how they may use and share your health information and how you can exercise your health privacy rights. In most cases, you should get this notice on your first visit to a provider or in the mail, and you can ask for a copy at any time. The provider cannot use or disclose information in a way that is not consistent with their notice.
Why you are asked to “sign” a form? The law requires your doctor, hospital, or other health care provider you see to ask you to state in writing that you received the notice. Please note, the law does not require you to sign the “acknowledgement of receipt of the notice”. Signing does not mean that you have agreed to any special uses or disclosures of your health record. Refusing to sign the acknowledgement does not prevent the entity from using or disclosing health information as the rule permits it to do – in service of your health. If you refuse to sign the acknowledgement, the provider must keep a record that they failed to obtain your acknowledgement.
Connected Health Medical Services, LLC is required by the HIPAA Privacy Rules to obtain your consent in order to share your medical information for certain reasons. This consent will be in effect for as long as Connected Health Medical Services, LLC provides service to you. 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 website.
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you:
Get an electronic or paper copy of your 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 the request. We may charge a reasonable, cost-based fee.
Ask us to correct your medical record.
You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this. We may say “no” to your request, but we’ll tell you why in writing within 60 days.
Request confidential communications.
You can ask us to contact you in a specific way (for example, home or cell phone or email) or to send mail to a different address. We will say “yes” to reasonable requests.
Ask us to limit what we use or 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 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 that you have asked us to make). We’ll provide one accounting 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 feel your rights are violated.
You can complain with the US Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington DC 20201, calling 1-877-696-6775, 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
• Include your information in an EMR system
• If you are not able to tell us your preference, for instance 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.
We typically use or share your health information in the following ways:
1. To treat you:
• We can use your health information and share it with other professionals who are treating you. In example: A doctor treating you for an injury asks another doctor about your overall health condition.
2. Run our organization:
• We can use and share your health information to run our practice, improve your care, and contact you when necessary. In example: We use health information about you to manage your treatment and services.
3. Bill for your services:
• We can use and share your health information to bill and get payment from health plans or other entities. In example: We give information about you to your health insurance plan so it will pay for certain services.
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.fov/ocr/privacy/hipaa/understanding/consumers/index.html.
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.
• Respond to organ and tissue donation requests – we can share health information about you with organ procurement organization.
• Work with medical examiner or funeral director – we can share your information with a coroner, medical examiner, or funeral director if you become deceased.
• 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
• In response to a court or administrative order, or in response to a subpoena
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 five 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.

Acknowledgement of Privacy Policy & HIPAA


Acknowledgement of Privacy Policy & HIPAA

I hereby acknowledge that I have reviewed and received a copy of Connected Health Medical Services, LLC’s (CHMS) Notice of Privacy Practices attached hereto explaining:
• How CHMS will use and disclose my protected health information
• My privacy rights with regard to my protected health information
• CHMS’s obligations concerning the use and disclosure of any protected health information
CHMS will share this information with individuals and providers as needed to coordinate your care, provide medical, case management and health coaching services, arrange for delivery of your medication, schedule with internal or external providers, discuss your treatment, or discuss payment. This information may then be further disclosed.
CHMS is permitted to communicate PHI to/with me via the email specified below and/or via text or phone call to the number indicated below.
I authorize CHMS to share, or limit the sharing of, my Personal Health Information as follows:
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By signing this form, I agree to the consent to share information with CHMS. I also understand that if I have any questions or complaints, I may contact: Betty Rich @ 724-933-4300 or email HIPAA@chforu.com.
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By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

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