GENERAL
Any information received will be kept confidential and private at all times. ASA Wellness values the safety and privacy of all clients. Results derived from our services is intended for the sole use of the individual and entity to whom it is addressed, and may contain information that is privileged, confidential, and exempt from disclosure under applicable law. You are hereby notified that any dissemination, distribution, or duplication of this transmission by someone other than the addressee or it’s designated agent is strictly prohibited.
SECTION I: HEALTH RISK ASSESSMENT
All results are kept confidential as well as all HRA are complaint with the latest requirements of the Health Insurance Portability & Accountability Act (HIPPA), HITECH amendments, and the Genetic Information Nondiscrimination Act (GINA).
SECTION II: IN- PERSON SERVICES
CONSENT TO PROCEDURES: I hereby authorize and consent to the drawing of blood samples via venous blood draw. As partial consideration for the services provided hereunder, I hereby release Vendor and any other organizations associated with this screening and their respective affiliates, directors, officers, shareholders, contractors, employees, successors, and assigns, from any liability arising from or in any way connected with the services provided hereunder or from the data derived there from. I understand that:
1. The data derived from the test is considered preliminary only and does not constitute a diagnosis.
2. If the results of my test suggest that I may be at risk of heart disease or diabetes, I should contact my personal physician for follow up.
3. The responsibility for initialing a follow up exam to confirm the results of this screening and obtain professional medical assistance is mine alone and not that of any other individual organization associated with this screening.
OSTEOPOROSIS STATEMENT: I hereby authorize and consent to the ultrasound measurement of my calcaneus (heel bone) using peripheral ultrasound technology for the purpose of osteoporosis screening. The results can be used in conjunction with other clinical risk factors as an aid to my physician in the diagnosis of osteoporosis and medical conditions leading to reduced bone density, and ultimately in the determination of fracture risk. I further understand it is my responsibility for initialing a follow up exam to confirm the results of this screening and obtain professional medical assistance is mine alone.
BODY COMPOSITION: I understand that under NO circumstance should I participant in the body composition screening if I have any of the following:
1. Medical electronic device such as pacemaker.
2. Pregnancy
3. Electronic life support systems or portable electronic medical devices.
PRIVICY: I understand that none of the above results or personal information will be shared with any outside source or agency without my written consent.