Robb Wolf Health Questionnaire

Robb Wolf

Wired to Eat Panel

If you are unsure or do not have the information, you may input N/A and move to the next section.

Personal Information and Consent
Personal Information
Name*
First Middle Initial Last
Date of Birth*
Gender*
- Male
- Female
Ethnicity*
Health risk may vary depending on ethnicity
Address*
Street Address City State ZIP Code
Cell Phone*
Employer*
Occupation
Work Phone*
Email Address*
Personal Information
I understand my personal information will not be shared by SpecialtyHealth without my written consent.*
This program is a health and wellness program, therefore we do not bill or take assignment of your health benefits. Once you complete your Health Questionnaire, you may pay for the program you selected over a secure web portal. Thanks you for your participation in Robb Wolf’s

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Authorization
I hereby consent to and authorize the treating physician, associated personnel, and any other consulting physician called in by the above, to assess or provide first aid and to render medical treatment and health care services to the patient named on this form. I further consent to and authorize procedures or services which may be deemed necessary by said designated or consulting physician. I have been given no guarantee and rely on none as to the result of any assessment, first aid, treatment, or examinations. I am aware that the practice of medicine and surgery is not an exact science, and I acknowledge that no guarantees have been made to me as to the results of any assessment, first aid, diagnostic, medical, surgical, or therapeutic treatments, procedures, or examinations. I hereby authorize the physicians and staff involved in SpecialtyHealth's Wellness and Prevention Program to utilize my medical information obtained through the Wellness and Prevention Program for the purpose of research. Research may include individual case studies and/or compilations of group/population data, which may be published and/or presented in lectures. All personal and medical information will be kept confidential. A personal ID will be assigned to each individual participant to protect his/her privacy. NOTICE: you are entitled to a copy of yours records upon request; however, pursuant to Nevada law, your records may be destroyed after 6 years.
Initial Authorization*
Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. UNDERSTANDING YOUR PROTECTED HEALTH INFORMATION (PHI) Understanding what is in your health record and how your health information is used will help you to ensure its accuracy. It will also allow you to better understand who, what, when, and why others may access your health information and assist you in making informed decisions when authorizing disclosure of your protected health information to others. When you visit us, we keep a record of your symptoms, examination, test results, diagnosis, treatment plan, and other medical information. We also may obtain health records from other providers. In using and disclosing this protected health information (PHI), we will follow the Privacy Standards of the federal Health Insurance Portability and Accountability Act (HIPPA), 45 CFR Part 464. This law allows us to use and disclose PHI without your specific authorization for treatment, payment, and health care operations.
- Treatment means providing, coordinating, or managing health care and related services by one or more health care providers.
- Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities, and utilization review.
- Health care operations include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis, and customer service.
We may contact you to provide appointment reminders of information about treatment alternatives or other health-related benefits and services that may be of interest to you. All other uses and disclosures require your specific authorization. HIPAA prohibits the sale of PHI without your authorization and allows for you to opt out of fundraising communications.

I HAVE RECEIVED AND UNDERSTANDING THE WELLNESS AND PREVENTION PROGRAM IS NOT A MEDICAL PROGRAM AND THAT ANY INFORMATION REGARDING MY RESULTS AND RECOMMENDATIONS WILL NOT BE SHARED WITHOUT MY CONSENT
I have received or I have been provided the opportunity to receive a copy of the "Notice of Privacy Practices" that explains when, where, and why my confidential health information may be used or shared. I acknowledge that SpecialtyHealth Clinic, the physicians, the nurses, and other SpecialtyHealth staff may use and share my confidential health information with others in order to treat me, in order to arrange for payment of my bill, and for issues that concern SpecialtyHealth's operations and responsibilities. I further acknowledge that I understand that if I have any questions regarding this Notice or wish to file a complaint, I may contact the SpecialtyHealth Privacy Officer in writing. I also understand that no other staff member, physician, nurse, or any other person is authorized to accept a request to exercise my rights but the Privacy Officer for SpecialtyHealth Clinic.
Initial Acknowledgement of Receipt*

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Understanding Your Health Information Rights
You have the right to:
- Request restrictions on certain uses and disclosures of protected health information, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. You should address your request in writing to the Privacy Officer (see next page). We are not required to agree to a requested restriction and will notify you within 30 days in writing if we cannot agree to the restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it.
- Obtain a paper copy of this notice and upon written request, inspect and obtain a copy of your health record for a fee of $0.60 per page and the actual cost of postage per NRS 629.061. You are not entitled to access or to obtain a copy of psychotherapy notes or information complied for legal proceedings. Copies of your records, including materials from other providers, will be provided within 30 days of receipt of your request. If payment is not made with delivery of the records, you will be billed for this service. You may also request an electronic copy of your health information held in an EHR.
- Amend your health records by submitting a written request with the reasons supporting the request to the attention of the Privacy Officer. In most cases, we will respond within 30 days. We are not required to agree to the requested amendment. If your clinician disagrees with the amendment, you will be notified in writing of the following:
  - The basis for the denial;
  - Your right to file a statement of disagreement to be kept in your file and included in future PHI disclosures;
  - Your right to complaint to the covered entity or Secretary Health and Human Services
  - Contact information for the covered entity’s privacy officer.
- Obtain an accounting of disclosures of your health information. The right to know with whom your information has been shared.
We are not required to account for disclosures for treatment, payment operations, or pursuant to authorization, among other exceptions. On request, you will be provided a report of the entities with whom your PHI was shared. Request in writing to the Privacy Officer that we communicate with you by a specific method and at a specific location. We will typically communicate with you in person; or by letter, fax, e-mail, and/or telephone. Revoke and authorization to use or disclose PHI at any time except where action has already been taken.
- You may opt to restrict disclosure of your PHI to health plans if you pay out-of-pocket in full for goods or services.
- Our health providers may share immunization records directly with schools with either written or oral consent from a parent or guardian or the individual, if the individual is an adult or emancipated minor.
Initial Health Information Rights*
Understanding our Responsibility
We are required by law to maintain the privacy of your protected health information and to provide you with notice of our legal duties and privacy practices with respect to protected health information. We have the right to change our notice of privacy practices and we will apply the change to your entire PHI. We post notice of any changes to our privacy policy in the waiting room and make a copy available to you upon request. Federal law requires that we seek your acknowledgement of receipt of this Notice of Privacy Practices, effective April 14, 2003. Please signify your acknowledgement with your signature beneath the following statement (Release of Information to Someone Designated by The Patient):
Initial Understanding our Responsibility*

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DISCLAIMER: This is not an insurance product. Many of the items may not be covered by your insurance company and therefore will be your responsibility. Healthcare professional availability for certain services may be dependent on licensure, scope of practice restrictions, or other requirements in the state. The information provided is not a substitute for your doctor’s care and should be used as a practical guide to better health through lifestyle choices.

Wired to Eat Panel

Personal Information and Consent

Personal Information

Personal Information

Health History

Current and Past History

Preventative Health:

Family History

Sleep

Readiness Assessment

Authorization

Notice of Privacy Practices

Understanding Your Health Information Rights

Understanding our Responsibility

Release of Information