Elysium Wellness Club, LLC Liability Waiver and Release I hereby acknowledge and agree to the terms and conditions set forth in this Liability Waiver and Release (the “Waiver”) in consideration of being allowed to use the facilities, equipment, and services provided by Elysium Wellness Club, LLC (the “Gym”).
Assumption of Risk: I understand that participation in physical activities, workouts, and exercise programs at the Gym involves certain inherent risks and dangers, including but not limited to the risk of injury, permanent disability, or death. I acknowledge that I have been informed that it is advisable to consult with a physician or other qualified healthcare provider before beginning any exercise program, and I have either consulted with such professionals or have knowingly chosen to waive this recommendation. Release and Waiver: I, on behalf of myself and my heirs, executors, administrators, successors, and assigns, hereby release, waive, discharge, and covenant not to sue Elysium Wellness Club, LLC, its owners, employees, agents, representatives, and any affiliated entities (collectively referred to as the “Released Parties”) from any and all claims, demands, actions, causes of action, or liability for any injury, loss, damage, or death arising out of my participation in Gym activities. I understand and agree that this release and waiver of liability covers any and all claims, whether arising from negligence, breach of contract, or any other theory of legal liability, and it extends to any injuries, illnesses, or accidents that may occur on the Gym premises. I agree to be solely responsible for the safety and wellbeing of my guest and myself. I understand that the company does not provide supervision, instruction, or assistance for the use of the facilities and equipment. I agree to comply with all rules imposed by the company regarding the use of the facilities and equipment. I agree to conduct myself in a controlled and reasonable manner at all times, and to refrain from using any equipment in a manner inconsistent with its intended design and purpose. I understand and agree that the company is not responsible for property that is lost, stolen, or damaged while in, on, or about the premises.
I hereby grant Elysium, its representatives, employees, or agents the right to take photographs and video footage of you and your property while at Elysium and to use and publish these photos or videos in print and/or electronically. You agree that Elysium may use photographs or video footage of you with or without your name for any lawful purpose, including for such purposes as publicity, illustration, advertising and web content.
Indemnification: I agree to indemnify and hold harmless the Released Parties from any and all claims or liabilities asserted against any of them, and any costs, attorney’s fees, or expenses incurred as a result of any such claims or liabilities. Acknowledgment of Understanding: I acknowledge that I have read this Waiver, understand its terms, and voluntarily agree to be bound by its terms. I also understand that this Waiver is a contract and that, by signing it, I am giving up certain legal rights, including the right to sue the Released Parties. Emergency Medical Treatment: In the event of an emergency, I authorize the Gym to obtain any necessary medical treatment for me and agree to be financially responsible for any medical costs incurred. Governing Law: This Waiver shall be governed by and construed in accordance with the laws of the state of Nevada, and any legal actions arising from or related to this Waiver shall be brought exclusively in the state or federal courts located within the state of Nevada. Entire Agreement: This Waiver contains the entire agreement between the parties and supersedes all prior and contemporaneous understandings, agreements, representations, and warranties.
Notice of Privacy Practices – HIPAA 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. What is “Medical Information”? The term “medical information” is synonymous with the terms “personal health information” and “protected health information” for the purposes of this Notice. It essentially means any individually identifiable health information (either directly or indirectly identifiable), whether oral or recorded in any form or medium, that is created or received by a healthcare provider (me), Health plan, or others and relates to the past present or future physical or mental health or condition of an individual (you); the provision of healthcare (e.g. mental health) to an individual (you); or the past, present, or future payment for the provision of healthcare to an individual (you). I am a marriage and family therapist licensed by the state of Nevada Board of Examiners for marriage and family therapists and clinical professional counselors. I am a licensed alcohol and drug counselor, licensed by the state of Nevada through the board of examiners for drug and alcohol counselors. To create and maintain treatment records that contain individually identifiable health information about you. These records are generally referred to as “medical records” or “mental health records”, and this notice, among other things, concerns the privacy and confidentiality of those records and the information contained therein. Your physical and electronic records are stored securely and my electronic system is password protected.
Uses and Disclosures Without Your Authorization – For Treatment Federal privacy rules (regulations) allow health care providers who have a direct treatment relationship with the patient to use or disclose the patient’s personal health information, without the patient’s written authorization, to carry out the health care provider’s own treatment, payment, or health care operations. I may also disclose your protected health information for the treatment activities of any health care provider. This too can be done without your written authorization. An example of a use or disclosure for treatment purposes: If I decide to consult with another licensed health care provider about your condition, I would be permitted to use and disclose your personal health information, which is otherwise confidential, in order to assist me in the diagnosis or treatment of your condition. Disclosures for treatment purposes are not limited to the minimum necessary standard because physicians and other health care providers need access to the full record and/or complete information in order to provide quality care. The word “treatment” includes, among other things, the coordination and management of health care among health care providers or by a health care provider with a third party, consultations between healthcare providers, and referrals of a patient for health care from one health care provider to another.
PLEASE NOTE: I, or someone in my practice acting with my authority, may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you. Your prior written authorization is not required for such contact. Other Uses and Disclosures Without Your Authorization: I may be required or permitted to disclose your personal health information (e.g. your records) without your written authorization. The following circumstances are examples of when such disclosures may, or will be made: 1. If disclosure is compelled by a court pursuant to an order of that court. 2. If disclosure is compelled by a board, commission, or administrative agency for purposes of adjudication pursuant to its lawful authority. 3. If disclosure is compelled by a party to a proceeding before a court or administrative agency pursuant to a subpoena, subpoena duces cecum (e.g. a subpoena for mental health records), notice to appear, or any provision authorizing discovery in a proceeding before a court or administrative agency. 4. If disclosures compelled by a board, commission, or administrative agency pursuant to an investigative subpoena issued pursuant to its lawful authority. 5. If disclosure is compelled by a search warrant lawfully issued to a governmental law enforcement agency. 6. If disclosure is compelled or by the Nevada Child Abuse and Neglect Reporting Act (for example, if I have a reasonable suspicion of child abuse or neglect) or by the Nevada Elder Dependent Adult Abuse Reporting Law (if I have a reasonable suspicion of elder abuse or dependent adult abuse). 7. If disclosures are compelled or permitted by the fact that you are in such mental or emotional condition as to be dangerous to yourself or to the person or property of others, and if I determine that disclosure is necessary to prevent the threatened danger. 8. If disclosure is compelled or permitted by the fact that you tell me of a serious threat (imminent) or physical violence to be committed by you against a reasonably identifiable victim or victims. 9. If disclosures are compelled or permitted, in the event of your death, to the coroner in order to determine the cause of your death. 10. If disclosure is required or permitted to a health oversight agency for oversight activities authorized by law, including but limited to, audits, criminal or civil investigations, or licensure or disciplinary actions. 11. If disclosure is otherwise specifically required by law.
PLEASE NOTE: The above List is not an exhaustive list, but informs you of most circumstances when disclosures without your written authorization may be made. Other uses and disclosures will generally (but not always) be made only with your written authorization, even though federal privacy regulations or state law may allow additional uses or disclosures without your written authorization. Uses or disclosures made with your written authorization will be limited in scope to the information specified in the authorization form. Which must identify the information “in a specific and meaningful fashion.” You may revoke your written authorization at any time, provided that the revocation is in writing and except to the extent that I have taken action in reliance on your written authorization. In general, uses or disclosures by me of your personal information (without your authorization) will be limited to the minimum necessary to accomplish the intended purpose of the use or disclosure. Similarly, when I request your personal health information from another healthcare provider, health plan or healthcare clearinghouse, I will make an effort to limit the information requested to the “minimum necessary” to accomplish the intended purpose of the request. As mentioned above, in the section dealing with uses or disclosures for treatment purposes, the minimum necessary standard does not apply to disclosures to or requests by healthcare providers for treatment purposes because healthcare providers need complete access to information in order to provide quality care.
Your Rights Regarding Protected Health Information You have the right to request restrictions on certain uses and disclosures of protected health information about you, such as those necessary to carry out treatment, payment, or healthcare operations. I am not required to agree to your requested restriction. If I do agree, I will maintain a written record of the agreed upon restriction. You have the right to receive confidential communications of protected health information from me by alternative means or at alternative locations. You have the right to inspect and copy protected health information about you by making a specific request to do so in writing. This right to inspect and copy is not absolute. You have the right to amend protected health information in my records by making a request to do so in a writing that provides a reason to support the requested amendment. This right to amend is not absolute. You have the right to receive an accounting from me of the disclosures of protected health information made by me and the six years prior to the date on which the accounting is requested. As with other rights, this is not absolute. The right to obtain a paper copy of this notice from me upon request.
PLEASE NOTE: In order to avoid confusion or misunderstanding, I ask that if you wish to exercise any of their rights enumerated above, that you put your request in writing and deliver or send the writing to me. If you wish to learn more detailed information about any of the above rights, or their limitations, please let me know. I am willing to discuss any of these matters with you. As mentioned elsewhere in this document, I am the privacy officer of this practice.
Our Duties We are required by law to maintain the privacy and confidentiality of your personal health information. This notice is intended to let you know of our legal duties, your rights, and our privacy practices with respect to such information. We are required to abide by the terms of the notice currently in effect. We reserve the right to change the terms of this notice and/or my privacy practices and to make changes effective for all protected health information that we maintain, even if it was created or received prior to the effective date of the notice revision. If we make a revision to this notice, we will make the notice available at our office upon request on or after the effective date of the revision. As the privacy officer of this practice, we have a duty to develop, implement and adopt clear privacy policies and procedures for my practice and we have done so. We are responsible for assuring that these privacy policies and procedures are followed by any employees that work at Elysium Wellness Club or that may work there in the future. We have trained or will train any employees that may work so that they understand our privacy policies and procedures. In general, patient records, and information about patients, are treated as confidential in our practice and are released to no one without the written authorization of the patient, except as indicated in this notice or except as may be otherwise permitted by law. Patient records are kept secured so that they are not readily available to those who do not need them. You may complain to us and to the Secretary of the U.S. Department of Health and Human Services if you believe your privacy rights may have been violated by those who are practicing in our space. You may file a complaint with us by simply providing us with a writing that specifies the manner in which you believe the violation occurred, the approximate date of such occurrence, and any details that you believe will be helpful to us. We will not retaliate against you in any way for filing a complaint with us or with the Secretary. Complaints to the Secretary must be filed in writing. A complaint to the Secretary can be sent to the U.S. Department of Health and Human Services. (You can locate regional addresses at http://www.hhs.gov/ocr/hipaahealth.txt .) If you need or desire further information related to this Notice or its contents, or if you have any questions about this Notice or its contents, please feel free to contact us.
