Consent, Disclosure, and Disclaimer
I request that Katie Miller, homeopathic health coach, and/or Dr. Krista Klipfel perform homeopathy and holistic health mentorship and set up a program for the purpose of enhancing health in a variety of situations, supporting conventional care, and increasing general vitality.
I understand that Katie Miller is a CHC (certified health coach) and holds a Certificate in Clinical Homeopathy (C. Hom.) from the Lotus Health Institute, and was trained specifically by Dr. Robin Murphy, ND and homeopath for over 35 years. I understand that Katie Miller continues her education of natural health therapies through qualified organizations and persons such as the Weston A. Price Foundation, Denise Timofai (C. Hom., D. Hom.), The National Center for Homeopathy, Dr. Murphy, Joette Calabrese (Homeopath), Sue Meyer (Homeopath), Karen Allen (Homeopath), and Le Leche League resources.
I understand that Krista Klipfel received her degree in Physical Therapy in 2014, has extensive experience in helping clients with back pain and jaw pain, has additional training and enjoys using her knowledge in Fascial Strain-Counterstrain, Kinesiotaping, Cupping and Instrument-assisted Soft Tissue Mobilization. She has enthusiastically studied holistic health and homeopathy and is continuing her education in this area by acquiring her C.Hom. (Certificate of Clinical Homeopathy).
I understand that homeopathy and mentorship is not intended as diagnosis, treatment, prescription or cure for any condition, mental or physical, real or imaginary, and that it is not a substitute for regular medical care.
I understand that I am not required to participate or take anything suggested by Coach Katie, Dr. Krista, or anyone who is a member of TRUE HEALTH. I take full responsibility for my choices to take homeopathy or participate in any programs pertaining to diet or lifestyle.
I understand that payment of membership counts as signing this agreement.
HIPAA Non-Participation Statement
TRUE HEALTH has chosen to remain a non-covered entity under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) that went into effect in October, 2002. Participati0n would mean that dozens of government agencies would have virtually unlimited access to your private records without your consent.
Your records will be released only with your consent, or if required by law. This office will not file electronic insurance claims. You may file your own claim and this office will provide you with any documentation you may need to do so.
If you are signing for a dependent, understand that your consent for release is not contingent upon the consent of the dependent until they reach the age of 18.
I understand that payment of membership counts as signing this agreement.
TRUE HEALTH PRIVATE MEMBERSHIP AGREEMENT
I, ________________________, hereby apply for Membership in TRUE HEALTH – a private membership group. Upon making payment for membership, I accept the offer made to become a member and I express my agreement with the following clauses:
- This organization of members hereby declare that our primary purpose is to protect and maintain our right to freedom of choice regarding alternative therapies, alternative modalities of treatment, health care decisions and the health improvement practices in which we choose to participate – by asserting our constitutional, contractual, and civil rights.
- As members, we affirm our belief that the Constitution of the United States guarantees all Americans, particularly members of private organizations, the right of freedom of association, speech, assembly, belief, and associated activities. These are our inalienable rights.
- We declare and assert the right to select those who can be expected to give the wisest counsel and advice regarding alternative therapies, alternative modalities of treatment, health care decisions and the health improvement practices and to authorize those members who are most skilled to facilitate the actual performance and delivery of health assistance and improvement methods that they and we deem appropriate. We assert these rights under the Federal and State Constitutions, Feder and State law and the statues and regulations interpreting them.
- We claim our freedom to choose and accept for ourselves the types of health care modalities that we think are best for determining the cause and correction of our health challenges. We do this in order that we might achieve optimal health and well-being. We reserve the right to include traditional, non-traditional or unconventional health care options.
- More specifically, our mission is to provide members with the highest quality homeopathic and holistic education available. Our concern is for the whole person – body, mind, and spirit.
- TRUE HEALTH recognizes all persons as members, without respect to race, creed or religion, who are in accordance with our principles and policies. Membership is for the lifetime of TRUE HEALTH.
Client Name________________________________ Date_______________
Memorandum of Understanding
- I understand that those members of TRUE HEALTH that provide services or advice do so in the capacity of fellow member-facilitators in a private manner and not in the capacity as public health-care providers. I understand that within TRUE HEALTH, no Public-Doctor-Patient or Public-Therapy-Client relationship exists. Within TRUE HEALTH, I freely choose to change my legal status from that of a Public Health-Care Recipient, to that of a Private Membership care recipient. I realize that in doing so I relinquish certain Federal and State protections and privileges. I understand that it is my personal responsibility to evaluate the services offered and to educate myself as to efficacy, risks, or desirability. I agree that the actions I take, in this regard, are my own free-will decisions. Upon acceptance for membership, I will exercise my rights for my own benefit and agree to hold harmless TRUE HEALTH and member-facilitators from any unintentional liability that might result from the advice or services I receive, except for harm that could remotely result from an instance of “a clear and present danger of substantive evil” – as determined by TRUE HEALTH and as defined by the United States Supreme Court. Agree_____
- I understand and accept that, since TRUE HEALTH is protected by the First, Ninth, and Fourteenth Amendments to the United States Constitution, it is exempt from any action of Federal and State agencies entrusted to “protect the public” – as it relates to any complaints or grievances against TRUE HEALTH, its physical premises or equipment, its member-facilitators or other associated staff or consultants. All complaints or grievances will be settled by non-judicial mediation, within TRUE HEALTH. Also, those membership and private member records kept by TRUE HEALTH are strictly protected and can only be released upon written request of the subject member. Agree_____
- I agree that I am joining this Private Membership under the common law. I understand that members seek to help each other achieve and sustain better health. I accept that the facilitators, and other health-care providers, who are fellow members, offer advice, services, and benefits that are not necessarily conventional or traditional. Agree _____
- As a Member, my goal is to accept those health and wellness services that I feel will truly help me. I will choose procedures that I consider proper and have a reasonable chance of making my health and life better. I realize that no health screening, resulting conclusions or health care services are foolproof. For example, if I choose to forego drugs, surgery or treatments that have been recommended by others, in the public sector, I accept that risk. I assert my right of informed consent. Agree_____
- My activities within TRUE HEALTH are a private matter and I refuse to share them with any Federal or State regulatory enforcement agency, medical board, FDA, Medicare or Medicaid. The health and/or sickness records that I have shared with other members remain the property of TRUE HEALTH. I, in becoming a member, agree not to file malpractice, civil or criminal lawsuits against a fellow member, unless that member exposes me to a clear and present danger of substantive evil. I further agree that all TRUE HEALTH members are exempt from the provisions of any state Medical Practice Act, Federal Food Safety Modernization Acts, Codex Alimentarius or any similar federal or state legislation. Agree_____
- I enter into this agreement of my own free will, or on behalf of a designated dependent, without any pressure or promise of benefit. I affirm that I do not represent any state or federal agency whose purpose is to regulate the practice of medicine or any other health care system. I accept that membership does not entitle me to any voting interest in TRUE HEALTH. I acknowledge I am not liable for any debts, liabilities, suits or judgements against TRUE HEALTH. Agree_____
- I have read and understand this contract and any questions I had were answered fully to my satisfaction. This document consists of my entire agreement for membership and it supersedes any previous agreement I may have made. Agree_____
- I understand that my membership fee entitles me to receive those benefits declared by a facilitator to be general benefits, free of further charge. I also agree to pay, as levied, for those benefits that I request and receive that are declared to be special assessments, as per a posted fee schedule. Agree_____
- I understand that $10.00 is required for consideration for my membership. The term of membership begins with the date of the payment and acceptance of this agreement and continuing until the dissolution of TRUE HEALTH. I do certify, attest, and warrant that I have carefully read this application for membership and I fully understand and agree with all of the provision state herein.
Payment of membership invoice may take the place of your signature.