Healthcare Fitness Program Terms

HEALTHCARE FITNESS PROGRAM TERMS

This Healthcare Fitness Program Terms agreement ("Agreement") documents the conditions under which the Program Provider and the patient will participate in a structured fitness program that incorporates clinical oversight, exercise prescription, and health monitoring. Patient Name: Program Provider:

Patient Information

Emergency Contact

Insurance & Provider

Medical History

Program Details

Program Name: Start Date: Duration: Frequency:

Fees, Payment & Cancellation

Program Fee: $ Payment Terms:

Medical Clearance & Assumption of Risk

I represent that I have disclosed all known medical conditions, medications, and limitations to the Program Provider and certify that I have reached the age of majority or am signing with legal authority. I understand that participation in physical activity involves inherent risks, including but not limited to musculoskeletal injury, cardiovascular events, and other complications. I acknowledge that I have the ongoing responsibility to report any change in my health status to program staff and to discontinue activity if I experience adverse symptoms.

Consent to Treatment & Emergency Care

I authorize Program Provider personnel to perform routine assessments and first aid as appropriate during program activities. In the event of a medical emergency, I authorize the release of necessary medical information to emergency responders and consent to emergency treatment and transport if required. I agree to be responsible for costs incurred for emergency care and transportation.

Release, Indemnification & Limitation of Liability

To the fullest extent permitted by law, I hereby release, covenant not to sue, discharge and hold harmless the Program Provider, its agents, contractors, clinicians, instructors and employees from liability for any and all claims, demands, actions or causes of action for injury, loss or damage to person or property arising out of or in connection with my participation in the Program, except for claims arising from the Program Provider's gross negligence or willful misconduct. I agree to indemnify and hold harmless the Program Provider for any third-party claims resulting from my acts or omissions during program participation.

Confidentiality, Records & HIPAA Acknowledgment

I acknowledge that the Program Provider will maintain records of my participation and health information. Such information may be used and disclosed for treatment, program operations, quality assurance, and billing consistent with applicable law. I have received or been offered a copy of the Program Provider's privacy practices and understand my rights with respect to Protected Health Information.

I acknowledge receipt of the privacy practices and consent to the use and disclosure of my health information for program purposes.

I consent / decline to the use of de-identified or anonymized images or data for program evaluation, education, or quality improvement. (Check if consenting)

Termination, Modification & Governing Terms

The Program Provider may modify program content or schedule, or terminate participation if participant noncompliance or safety concerns arise. Fees for services rendered prior to termination remain payable in accordance with the Payment Terms. This Agreement is governed by the laws of the jurisdiction in which the Program Provider operates. If any provision is held invalid, the remaining provisions remain enforceable.

Acknowledgment and Certifications

By signing below, I certify that the information I have provided in this Agreement is true and complete to the best of my knowledge. I certify that I have read, understand, and agree to abide by the terms set forth herein, and that I have had the opportunity to ask questions about the program, risks, and alternatives. I understand that I may withdraw consent and discontinue participation at any time by notifying the Program Provider in writing.

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