Disclaimer & Service Waiver

Before you choose to use the services of Mold Environmental, please read the following information FULLY AND CAREFULLY. A Liability Waiver must be electronically signed.

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GOAL:

Our basic goal is to encourage people to become knowledgeable about and responsible for their own health, and to bring it to a personal optimum level. The information, resources, and services provided by Mold Environmental are designed to improve your health, but is not designed to treat any specific disease or medical condition. Reaching the goal of optimum health, absent other non-nutritional complicating factors, requires a sincere commitment from you, possible lifestyle changes, and a positive attitude. A Mold Environmental consultant is trained to evaluate your nutritional needs and make recommendations of dietary change and nutritional supplements. A Mold Environmental Consultant is not trained to provide medical diagnoses, and no comment or recommendation should be construed as being a medical diagnosis. Since every human being is unique, we cannot guarantee any specific result from our programs.

HEALTH CONCERNS:

If you suffer from a medical or pathological condition, you need to consult with an appropriate healthcare provider. A Mold Environmental consultant is not a substitute for your family physician or other appropriate healthcare provider. A Mold Environmental consultant is not trained nor licensed to diagnose or treat pathological conditions, illnesses, injuries, or diseases. If you are under the care of another healthcare provider, it is important that you contact your other healthcare providers and alert them to your use of nutritional supplements. Integrative Nutrition counseling may be a beneficial adjunct to more traditional care, and it may also alter your need for medication, so it is important you always keep your physician informed of changes in your nutritional program. If you are using medications of any kind, you are required to alert the Mold Environmental consultant to such use, as well as to discuss any potential interactions between medications and nutritional products with your doctor or pharmacist. If you have any physical or emotional reaction, discontinue their use immediately, and contact your Mold Environmental consultant to ascertain if the reaction is adverse or an indication of the natural course of the body’s adjustment to the therapy.

COMMUNICATION:

Every client is an individual, and it is not possible to determine in advance how your system will react to the supplements you need. It is sometimes necessary to adjust your program as we proceed until your body can begin to properly accept products geared to correct the imbalance. It is your responsibility to do your part by using your nutrition guidelines, exercise your body and mind sufficiently to bring your emotions into a positive balance, eat a proper diet, get plenty of rest, and learn about nutrition. You must stay in contact with the Mold Environmental consultant so we can let you know what is happening and the best course of action. You should request your healthcare provider, if any, to feel free to contact the Mold Environmental consultant for answers to any questions they may have regarding Integrative Nutrition counseling.

COMMUNICATION WITH OTHER PROVIDERS:

This disclaimer will serve as the client’s consent for Mold Environmental or any employee thereof to speak to anyone the client deems necessary, either in writing or verbally, unless that person is a medical provider. In which case a HIPPA form will need to be submitted to your provider giving them permission to speak with Mold Environmental or any employee thereof. Download HIPPA form.

PATIENT AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION:

I hereby give my consent for Mold Environmental to use and disclose protected health information (PHI) about me to carry out payment and health care operations.

I have the right to review the Notice of Privacy Practices prior to signing this consent.

Mold Environmental reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to the Office.

With this consent, Mold Environmental may call my home or other alternative designated location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out health care, such as appointment reminders, insurance items and any calls pertaining to my clinical care, including laboratory test results, among others.

With this consent, Mold Environmental may mail to my home or other alternative location any items that assist the practice in carrying out health care operations, such as test kits, supplements, lab requisitions, reminders, invoices, forms, etc.

With this consent, Mold Environmental may e-mail to my home or other alternative location any items that assist the practice such as test kits, supplements, lab requisitions, reminders, invoices, forms, etc. I have the right to request that Beyond Wellness restrict how it uses or discloses my PHI to carry out health care operations. The practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.

By signing this form, I am consenting to allow Mold Environmental to use and disclose my PHI to carry out health care.

I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, Mold Environmental may decline to provide treatment to me.

LICENSURE:

A Mold Environmental consultant is not licensed or certified by any state. However, a Mold Environmental consultant is trained by The Institute for Integrative Nutrition, Inc.® which provides a certificate of completion to students who have successfully met all course requirements, including a written exam. A license to practice Integrative Nutrition is not required in some states. Laws and regulations regarding certification and licensure requirements differ from state to state.

PAYMENTS & REFUNDS:

The agreed to fee and 1st or full payment is due at signing. No refunds shall be given for completed sessions/work. If client fails to adhere to recommendations, fails to complete weekly tasks as requested by the practitioner, the program will be terminated. No refunds will be given for terminated programs. Program fees cannot be transferred to a third party.

WAIVER:

A liability waiver must be signed by each client electronically prior to program start.

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