I, as a parent/guardian of a minor receiving treatment, do hereby agree and understand that I have been advised to remain on the premises during any such treatment, and waive any claim I may have resulting from failure to do so.
All staff members have my permission to seek medical attention for my child in case of an emergency.
Mojo SportClinic will provide lockable self storage lockers for valuables to be stored safely. I know and agree that Mojo SportClinic is not responsible for loss or damage to personal valuables.
The use of property, facilities, staff, equipment, and/ or services carries with it certain inherent risks that cannot be eliminated regardless of the utmost professional care taken to avoid injuries. Some of the activities involve situations, environments, or activities that may lead to illness, physical injuries, and psychological stress or damage. The specific risk varies from one activity to another and may range from 1) minor injuries such as scratches, bruises, sprains and embarrassment 2) major injuries such as joint or back injuries, broken bones, heart attacks, head injuries and psychological trauma 3) catastrophic injuries including paralysis or death.
I have read the previous paragraphs and I know, understand, and appreciate these and other risks that are inherent in the activities made possible by Mojo SportClinic, LLC. I hereby assert that my participation is voluntary and that I knowingly assume all such risks.
I further expressly agree that the foregoing waiver and assumption of risks agreement is intended to be as broad and inclusive as permitted by the law of the State of North Carolina and that if any portion thereof is held invalid, it is agreed that the balance shall, not withstanding, continue in full legal force and effect.
Intending to be legally bound, I do hereby, for myself, my heirs, executors, and administrators, waive, release and forever discharge any and all of my rights of claims for damages which I or my child may have or hereafter accrue to me or my child against the staff of Mojo SportClinic, LLC facility or assigns, and for any or all damages which may be sustained or suffered by me or my child in connection with this organization or with participation in events associated with this organization. All staff members have permission to seek medical attention for my child.
I hereby release, discharge and acquit Mojo SportClinic, it's agents, representatives, affiliates, employees or assigns of and from any and all liability, claim, demand, damage, cause of action, or loss of any kind arising out of resulting from my refusal to accept, receive or allow emergency and/or medical services, including but not limited to ambulance service, Emergency Medical Technician, physician or urgent care services.
- Indemnification and Hold Harmless:
I also agree to indemnify and hold the facility in use, its owners, officers, employees and agents harmless from all claims, actions, suits, procedures, costs, expenses, damages and liabilities, including attorney's fees brought a sa result of my involvement with Mojo SportClinic, LLC and to reimburse them for any such expenses incurred.
I acknowledge that my medical insurance will NOT be billed for services rendered by Mojo SportClinic. I am fully responsible for payment to this provider. I further understand that Mojo SportClinic is an out-of-network provider with no affiliations to any insurance company.
I hereby give permission for myself and my child to be viewed on any media source (edited or non-edited material) chosen by the officers, agents or staff at Mojo SportClinic, LLC to promote the services offered and that are performed by Mojo SportClinic, LLC and used to encourage other athletes to participate or make use of such services (for any marketing purposes).
I acknowledge have read the: HIPAA NOTICE OF PRIVACY PRACTICES
As required by the Privacy Regulations Promulgated Pursuant to the Health Insurance Portability and Accountability Act of 1996 (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. This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services. Uses and Disclosures of Protected Health Information: Your protected health information may be used and disclosed by our organization, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the organization, and any other use required by law. Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you. Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for equipment or supplies coverage may require that your relevant protected health information be disclosed to the health plan to obtain approval for coverage. Healthcare Operations: We may use or disclose, as‐needed, your protected health information in order to support the business activities of our organization. These activities include, but are not limited to, quality assessment activities, employee review activities, accreditation activities, and conducting or arranging for other business activities. For example, we may disclose your protected health information to accrediting agencies as part of an accreditation survey. We may also call you by name while you are at our facility. We may use or disclose your protected health information, as necessary, to contact you to check the status of your equipment. We may use or disclose your protected health information in the following situations without your authorization: as Required By Law, Public Health issues as required by law, Communicable Diseases, Health Oversight, Abuse or Neglect, Food and Drug Administration requirements, Legal Proceedings, Law Enforcement, Criminal Activity, Inmates, Military Activity, National Security, and Workers’ Compensation. Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500. Other Permitted and Required Uses and Disclosures Will Be Made Only with Your Consent, Authorization or Opportunity to Object, unless required by law. You may revoke this authorization, at any time, in writing, except to the extent that your physician or this organization has taken an action in reliance on the use or disclosure indicated in the authorization.
Your Rights: Following is a statement of your rights with respect to your protected health information. You have the right to inspect and copy your protected health information. Under federal law, however, you may not inspect or copy the following records; psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information. You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. Our organization is not required to agree to a restriction that you may request. If our organization believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use another Healthcare Professional. You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively, e.g., electronically. You may have the right to have our organization amend your protected health information. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice. Complaints: You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint. We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information, if you have any questions concerning or objections to this form, please ask to speak with our Director of Operations in person or by phone at 910‐338‐5545. Associated companies with whom we may do business, such as an answering service or delivery service, are given only enough information to provide the necessary service to you. No medical information is provided. We welcome your comments: Please feel free to call us if you have any questions about how we protect your privacy. Our goal is always to provide you with the highest quality services.