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You may revoke this authorization at any time in writing. Your PHI may be disclosed to public health agencies or law enforcement as needed to protect you or others. You have the right to inspect and copy your PHI except for certain legal limitations. You may ask us not to disclose your PHI for purposes of treatment, payment, or health care operations, as well as family members.

This must be specific in writing. You may ask your PHI to be amended. I hereby consent to voluntarily engage in an acceptable plan of personal fitness training. I understand that I may be required to undergo a graded exercise test prior to the start of my personal fitness training program in order to evaluate and assess my present level of fitness. I will be given exact personal instructions regarding the amount and kind of exercise I should do.

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Every effort, I have been told, will be made to minimize these occurrences by proper staff assessments of my condition before each personal fitness training session, staff supervision during exercise and by my own careful control of exercise efforts. I fully understand the risks associated with exercise, including the risk of bodily injury, heart attack, stroke or even death, but knowing these risks, it is my desire to participate as herein indicated.

I understand that this program may or may not benefit my physical fitness or general health. Notice: This is not required. I consent for medical photographs to be made of me or my child or for person whom I am legal guardian. By consenting to these medical photographs I understand that I will not receive payment from any party.

Refusal to consent to photographs will in no way affect the medical care I will receive. I understand the Practice will not condition my treatment, payment, enrollment in a health plan, or eligibility for benefits if applicable on whether I provide authorization for the requested use or disclosure. This authorization, unless revoked, expires one year from the Effective Date, as set forth below.

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