Client Agreement, Authorization & Waiver of Liability
*Authorization for Release of Health Information*
I do hereby authorize Fit Finders, LLC DBA DexaFit Gig Harbor and/or DexaFit, Inc. to forward the health and fitness information resulting from their services to me or any parties authorized by me via email, fax, mail, or through the private login page on the DexaFit website/app.
I understand that I may revoke/withdraw this authorization at any time by writing to DexaFit Gig Harbor at info.gigharbor@dexafit.com, except to the extent that action has already been taken to release this information.
This authorization shall remain valid unless revoked. Fit Finders, LLC DBA DexaFit Gig Harbor and/or DexaFit, Inc. will not forward my health and fitness information if I do not consent to this authorization.
*Client HIPAA Consent*
I understand I have certain rights to privacy regarding my protected health information under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). By signing this consent, I authorize Fit Finders, LLC DBA DexaFit Gig Harbor and/or DexaFit, Inc. to use and disclose my protected health information to carry out:
Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment)
Obtaining payment from third-party payers (e.g., HSA/FSA/HRA)
The day-to-day operations of Fit Finders LLC DBA DexaFit Gig Harbor and/or DexaFit, Inc.
I understand I have the right to request restrictions on how my protected health information is used and disclosed for treatment, payment, and healthcare operations. While you are not required to agree to these requested restrictions, you are bound to comply if you do agree.
I understand that I can revoke this consent in writing at any time. However, any use or disclosure before I revoke this consent will not be affected.
*Financial Responsibility Policy*
I accept financial responsibility for all charges for services provided to me and/or my family members. I verify that I am the cardholder and authorize Fit Finders, LLC DBA DexaFit Gig Harbor to charge the card on file in my account for purchases, Late/No-Show fees, late cancellation, or rescheduling fees.
There are no refunds for tests rendered or partial refunds for tests left unused on packages purchased. Tests do not roll over from year to year, and we do not remind clients of unused tests. The client must cancel packages/subscriptions before the renewal date; no refunds will be granted for renewed charges. A renewal notice will be sent 20 days before the renewal charge is processed for subscriptions longer than one month.
We can provide an itemized receipt upon request for reimbursement for HSA/HSA/HRA benefits.
*Use and Disclosure of Protected Health Information (PHI) Policy*
- Purpose -
To ensure the confidentiality, integrity, and availability of Protected Health Information (PHI) in compliance with applicable laws and regulations.
- Scope -
This policy applies to all employees, contractors, and third parties handling PHI on behalf of Fit Finders, LLC DBA DexaFit Gig Harbor.
- Definitions -
Personal Health Information (PHI): Information related to an individual’s health, including DEXA scan results, that identifies the individual.
Use: Sharing, examining, or analyzing PHI within the business.
Disclosure: Releasing or providing access to PHI outside the business.
- Policy -
General Use and Disclosure: PHI may only be used or disclosed as permitted by law and as necessary for providing DEXA scans and related services.
Treatment: PHI may be used to provide, coordinate, or manage DEXA scan services.
Payment: PHI may be used to obtain payment for DEXA scan services.
Operations: PHI may be used for business operations necessary to support treatment and payment functions.
Authorization: Uses and disclosures of PHI for purposes other than treatment, payment, or operations require the patient’s written authorization.
Minimum Necessary Standard: Efforts must be made to limit PHI to the minimum necessary to accomplish the intended purpose.
Business Associates: PHI may be disclosed to business associates performing functions on behalf of the business, provided they agree to protect the information and comply with legal requirements.
Safeguards: Administrative, physical, and technical safeguards must be implemented to protect PHI against unauthorized use or disclosure.
Patient Consent: I consent to allow Fit Finders, LLC DBA DexaFit Gig Harbor to use their DXA scanner to perform a body composition and/or bone densitometry scan, with full awareness that the technology uses low-dose x-rays.
Records Review for Research: I also authorize Fit Finders, LLC DBA DexaFit Gig Harbor to review my records to determine my body scan’s qualifications for approved clinical studies and to contact me if I have potential as a research candidate. No records are ever provided to other persons for research purposes, except by my specific written approval.
Training: All workforce members must receive training on this policy upon hire and annually thereafter.
Violations and Sanctions: Violations of this policy may result in disciplinary action and potential legal penalties.
Policy Review and Revision: This policy must be reviewed annually and whenever there are significant changes in the law or business practices.
*Waiver and Agreement Policy*
I do hereby release all representatives of Fit Finders, LLC DBA DexaFit Gig Harbor and/or DexaFit, Inc. that are acting upon their behalf from any responsibility or liability for any injury or damage to myself, including those caused by the negligent act or omission of any of those mentioned or others acting on their behalf or in any way arising out of or connected with my participation in services, activities, or programs of Fit Finders LLC DBA DexaFit Gig Harbor and/or DexaFit, Inc.
I am voluntarily participating in the Fit Finders, LLC DBA DexaFit Gig Harbor and/or DexaFit, Inc DXA scan service and/or other Fit Finders, LLC dba DexaFit Gig Harbor and/or DexaFit, Inc services, including Dexa Body composition scan, VO2 Max, and RMR Metabolic Testing. I hereby agree to expressly assume any and all risks of injury and death resulting from participation in the aforementioned services.
I further hereby declare myself to be physically sound and suffering from no condition, impairment, disease, infirmity, or other illness that disqualifies me from receiving services from Fit Finders, LLC DBA DexaFit Gig Harbor and/or DexaFit, Inc. I acknowledge that I have permission to participate or that I have decided to participate in these services without my physician's approval and do hereby assume all responsibility for my participation. I also certify that I am not pregnant or trying to become pregnant.
I take full responsibility for any action I take after my visit to Fit Finders, LLC, doing business as DexaFit Gig Harbor and/or DexaFit, Inc. I do not hold any Fit Finders, LLC representatives, doing business as DexaFit Gig Harbor or DexaFit, Inc., responsible or liable for any adverse effects or complications arising from their services or opinions.
Confidentiality. The information based on the observations made during the DXA scan, VO2max, or RMR analysis, and subsequent report is treated as privileged and confidential. However, it may be used for statistical or scientific purposes, and your right to privacy may be retained.
I understand that Fit Finders, LLC DBA DexaFit Gig Harbor and/or DexaFit, Inc. does not diagnose or interpret the DXA results and that any further review or analysis of the report is between the individual and their primary care physician.
*Terms & Conditions*
By checking, I attest that I am NOT pregnant, over 350 pounds, and have not received any contrast dye treatments in the last 48 hours. I have read and agree with the Terms and Conditions available to read at https://www.gigharbor.dexafit.com/terms-and-conditions AND do consent to participate in the services rendered by DexaFit Gig Harbor.
*Cancellation/Late Arrival Policy*
DexaFit is an appointment-based office. If you cannot make your appointment, please give us as much notice as possible so that others have the opportunity to book an appointment. Please notify us of cancellation or reschedule 24 hours prior to your appointment. If you are more than 10 minutes late, your appointment may need to be rescheduled to avoid disrupting other appointments, and a late cancellation fee will be applied. If you are more than 10 minutes late without notification to our Dexafit team, your appointment will be canceled. If you arrive unprepared for a test or decide not to do a scheduled test during the appointment, a late cancellation fee will be applied to the test we cannot perform.
In the event of a no-show or reschedule/cancellation less than 24 hours prior to the appointment, you will be charged $75 PER TEST (DEXA, VO2 Max, RMR) scheduled, regardless of when the appointment was booked or how many spaces were available at the time. Prepaid appointments are nonrefundable if you do not show or cancel after policy time.
***VO2 Max/RMR testing for persons under the age of 18 years must be accompanied by a legal guardian and provide written and verbal consent upon the performance of services. Dexa body composition scans are not performed for persons under 18 years of age.***
----------------------------------------------------------------------------------------------
I have reviewed the information above and hereby consent to participate in the services provided by Fit Finders LLC, doing business as DexaFit Gig Harbor. I affirm that I have provided all information truthfully and to the best of my knowledge. As the client, I take full responsibility for the services I choose and the conditions under which I participate in them.