REQUEST TO PARTICIPATE IN THE COMPLETE HEALTH IMPROVEMENT PROGRAM (CHIP)

Request to Participate

The CHIP Program is a lifestyle education course which encourages a positive outlook on life while helping participants make lifestyle changes regarding their diet and exercise. I understand that I may expect some physical changes such as reduction in elevated blood sugar levels, reduction in elevated blood pressure, improved total cholesterol ratio, loss of weight and possible reduction in chronic disease medications. I accept full responsibility for informing my physician of my participation in the CHIP program, my test results and any medical problems I experience while participating in the program. I will consult with my physician before making any changes in my medications. To the best of my knowledge, I have no physical or medical conditions that would be adversely affected by participating in the CHIP program. I agree to take full responsibility for any food allergies or in tolerances that I may have and I understand that this involves my personal inquiry about ingredients of any food served. I release the CHIP Program, Lifestyle Medicine Institute, LifestyleMedicine Options, LLC staff, and any of their respective representatives or affiliates from any liabilities, whether caused by negligence or otherwise arising out of my participation in the CHIP program. I have carefully read the Request to Participate and I have had an opportunity to ask questions about the CHIP program and possible risks. My questions have been answered to my satisfaction. I also understand that I am free to ask my questions pertaining to the CHIP program at any time.

First Name

Last Name

Date of Signing

YYYY

I have read and understand the following:

NOTICE OF PRIVACY PRACTICES We protect personal health information we collect about you by maintaining physical, electronic, and procedural safeguards that meet or exceed applicable law. If you want to limit our disclosing of this information, please submit your wishes to us in writing.  Protected Health Information We Collect and May Disclose The protected health information we collect about you comes from the following sources: ☐ Information received from your physician or other healthcare provider. ☐ Information we receive from on enrollment forms, assessment surveys, or other forms. ☐ Information we receive from other sources such as caregiver, insurer, employer and other third parties. We may disclose any of your protected health information to doctors, hospitals, health care providers, pharmacies, insurance companies, family members or other persons involved directly in your individual care as long as this information is directly related to health services or your individual care. Your protected health information will not be used for marketing purposes unless you provide verbal or written consent. Your protected health information may be disclosed in the form of a “limited data set” for research, public health, and health care operations. A “limited data set” does not contain any direct identifiers of individuals (e.g. should not include name, address, phone number, social security number, medical number, etc.), but may contain any other demographic or health information needed for research public health or health care operations purposes. I understand and acknowledge receipt of this Notice of Privacy Practices. I also authorize the payment of medical and government benefits to this providing organization for CHIP Services received.

yes

Digital Signature

First Name

Last Name

Date of Signature

YYYY