Signature of Client or Parent/Guardian if Client is a Minor
Emergency Medical Consent
The undersigned hereby grants to any Stable Transformation affiliate/ employee/ intern/ volunteer the authority to receive information pertaining to the emergency health care of the client named below and to make emergency health care decisions with respect to the client if the undersigned is unavailable to obtain such information or make such decisions.
Emergency Medical Non-ConsentIf the undersigned does not desire to grant any Stable Transformation, LLC affiliate/ employee/ intern/volunteer information or to make health care decisions for the client if the undersigned is unavailable, please initial on the line below and state the procedures to be followed if the client becomes ill or is involved in an accident and the undersigned is unavailable.
I hereby authorize Stable Transformation, LLC. to release and/or exchange protected health information for the above stated client for the duration of services received from Stable Transformation, LLC. with:
Purpose of Contract: This form implements the requirements for client authorization /consent to use and disclose health information protected by the federal health privacy law (45 C.F.R. parts 160, 164), and the federal drug and alcohol confidentiality law (42 C.F.R. part 2)
Redisclosure: Once information is disclosed pursuant to this signed authorization, I understand that the federal health privacy law (45 C.F.R. Part 164) protecting health information may not apply to the recipient of the information and, therefore, may not prohibit the recipient from redisclosing it. Other laws, however, may prohibit redisclosure. When this agency discloses mental health and developmental disabilities information protected by federal law (42C.F.R. Part 2), we must inform the recipient of the information that redisclosure is prohibited except as permitted or required by this law.
Stable Transformation, LLC.
Confidentiality Agreement and Equine Activity Liability Release and Risk
By signing below, I agree not to disclose any client names, treatment information or identifying information pertaining to any client, past, present or future, of Stable Transformation, LLC. to anyone who is not affiliated with Stable Transformation, LLC. This confidentiality agreement is effective the date of the signing of this agreement, and is forever binding after my association with Stable Transformation, LLC, ends.
Equine Liability Release and Risk Acknowledgement:
1.Parties. The parties to this document are Stable Transformation, LLC (hereinafter “Stable Transformation”) and
2. Apportionment of Liability. In consideration of client being allowed to attend, participate in, or observe activities sponsored or conducted by Stable Transformation, or be present on the property on which Stable Transformation conducts its activities, client does agree to hold harmless and release Stable Transformation, its officers, members, managers, agents, employees, representatives, assigns, affiliated organizations, insurers, and all others acting on Stable Transformation's behalf and the owner(s) of any horse or other property used by Stable Transformation, from all claims, demands, causes of action, and legal liability, whether the same be known or unknown, anticipated or unanticipated even if due to negligence and/or other clients' acts or omissions. Client does further agree to waive all rights which may otherwise arise from an injury to client or client's property, and shall not bring any claims, demands, legal actions or causes of action, against Stable Transformation, those persons described above, or any person or entity, for any economic or non-economic losses due to bodily injury, death, or property damage arising out of the activities of Stable Transformation or client's presence on or proximity to property used by Stable Transformation.
3. Indemnity. Client agrees to be responsible for any and all damages, injuries, or loss of life caused by client or a horse in the care, custody and control of client, and to indemnify Stable Transformation and all parties described above, for any losses or expenses (including attorney fees) which they incur in connection with claims related to client.
4. Risks. According to the North American Horseman's Association, numerous obvious and non- obvious inherent risks are always present in horseback riding and being around horses, despite all safety precautions. No horse is a completely safe horse. Horses are 5 to 15 times larger, 20 to 40 times more powerful and 3 to 4 times faster than a human. If a client falls from a horse to the ground it will generally be at a distance of 3 to 5 feet, and the impact may result in injury to the client. If a horse is frightened or provoked it may divert from its training and act according to its natural instincts which may include, but are not limited to: stopping short, changing direction or speed at will, shifting its weight from side to side, bucking, rearing, biting, kicking or running from danger. These risks exist for any person around a horse, whether mounted or on the ground. Client acknowledges these risks and states that she/he is not relying on Stable Transformation to advise of all the risks.
5. Acknowledgment and Assumption of Risks. Client acknowledges that she/he bears responsibility for her/his own safety and client should not participate in any client activity unless she/he is confident that she/he can do so safely. Participation in equine activities with or conducted by Stable Transformation constitutes a knowing and voluntary assumption of all risks associated with equine activities involving Stable Transformation or being present on or using Stable Transformation property (including but not limited to inherent risks and the risk of negligence by Stable Transformation or others).
6. Helmet Use. Client acknowledges that wearing a properly fitted and secured client riding helmet which meets or exceeds the quality standards of the SEI Certified ASTM Standard F1163 while riding, mounting, dismounting and being near horses may reduce the severity of head injuries or prevent death occurring as the result of a fall or other occurrence. Stable Transformation makes no representations as to the condition, effectiveness or suitability of any helmet it may allow client to use. All helmet related risks are assumed by client.
7. Visitors. Should client bring to Stable Transformation any person who is not a party to an Equine Activity Liability Agreement with Stable Transformation, client agrees to educate them as to the risks of being around horses and horse operations, supervise them, be solely responsible for their safety, and to be financially responsible for any injury or loss caused by or suffered by any such person.
8. Safety Rules. Client agrees to follow such rules for safety as are attached or are subsequently provided to them, or posted. Client acknowledges that failure to follow Stable Transformation safety rules or the directions of Stable Transformation's staff may put her/him at risk of, or increase the risk of, personal injury.
9. Premises Inspection. Client has inspected the farm's premises and facilities and/or have in some other way satisfied himself/herself that the condition of the premises and the facilities will provide an adequate and reasonable level of safety for client and any guests, or visitors they bring on the premises.
10. Other Terms. This document states the entire agreement between the parties as to liability and may not be changed, except in writing signed by the parties. The benefits of this agreement, including the release of legal liability, waiver of rights, indemnity and covenant not to sue, are intended to benefit others, including Stable Transformation’s officers, directors, shareholders, members, managers, agents, employees, representatives, assigns, affiliated organizations, insurers, and all others acting on Stable Transformation’s behalf and the owner(s) of any horse or other property used by Stable Transformation. This agreement shall be binding upon Stable Transformation, client, and client's heirs or estate, when signed by the parties. If any clause, phrase or work is in conflict with State Law then that single part is null and void. This agreement and acknowledgments shall remain in force until terminated by client through written notice to Stable Transformation at the address above. The Metropolitan General Sessions Court of Nashville-Davidson County shall be the exclusive venue for any litigation between client and the parties described above.
WarningUnder Tennessee Law, an equine professional is not liable for an injury to or the death of a participant in equine activities resulting from the inherent risks of equine activities, pursuant to Tennessee Code Annotated, title 44, chapter 20.
This notice describes how medical information about you may be used and disclosed, and how you can get access to your health information. Please Read Carefully.
Protecting Your PrivacyProtecting your privacy and your medical information is at the core of our business. We recognize our legal and ethical obligation to keep your information secure and confidential whether it be orally, on paper, or in an electronic form.
How we might use your medical informationWe will use your medical information for providing treatment, such as by looking at your records to use your medical history for current treatment; and/or payment, such as when a payer requests copies of our medical information to pay a claim; and/or for healthcare operations, such as for internal auditing. We may contact you to help provide you with information concerning your health. We may also contact you to remind you of an upcoming appointment, taking care not to reveal any of your medical information. You have a right to ask us not to contact you using this method. I understand that as a part of my healthcare, Stable Transformation originates and maintains health records describing my health history, symptoms, examination on test results, diagnosis, treatment, and any plans for future care of treatment for up to seven years after the date of my last session at Stable Transformation. I understand that this information serves as a basis for planning my care and treatment, a means of communication among the many health professionals who contribute to my care, a means by which a third-party payer can verify that services billed were actually provided, and a tool for routine healthcare operations such as assessing quality and reviewing the competenceof healthcare professionals.
Use and disclosure for your health information in certain special circumstances; the following circumstances may also require us to use or disclose your health information without your consent or authorization:
1. To public health authorities and health oversight agencies that are authorized by law to collect information.
2. Lawsuits and similar proceedings in response to a court or administrative order.
3. If required to do so by a law enforcement official.
4. When necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. We will only make disclosures to a person or organization able to help prevent the threat.
5. If you are a member of US or foreign military forces (including veterans) and if required by the appropriate authorities.
6. To federal officials for intelligence and national security activities authorized by law.
7. To correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official.
8. For workers compensation and similar programs
Your rights regarding your health information
1. You can request that Stable Transformation, LLC. communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home rather than work. We will accommodate reasonable requests.
2. You can request a restriction in our use or disclosure of your health information for treatment, payment, or healthcare operations. Additionally, you have the right to request that we restrict our disclosure of your health information to only certain individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you.
3. You have a right to ask for complete accounting of disclosures that were not authorized or otherwise permitted as listed above. You may revoke your authorization to disclose your medical information at any time.
4. You have the right to inspect and obtain a copy of the health information that may be used to make decisions about you, including patient medical records and billing records. In order to receive a copy of your records, Stable Transformation will charge you fifty cents ($.50) per page. You must submit your request in writing and in person to Stable Transformation, LLC., Attn: Office Manager. Before receiving your records, you must make an appointment with your therapist, so he or she can go over your records with you, in case you have any questions.
5. You may ask to amend your health information if you believe it is incorrect or incomplete, and as long as the information is kept by or for Stable Transformation. To request an amendment, your request must be made in writing and submitted to Stable Transformation, LLC., Attn: Office manager. You must provide us with a reason that supports your request for amendment.
6. You have a right to receive a copy of this Notice of Privacy Practices. You may ask us to give you a copy of this Notice at any time. Stable Transformation reserves the right to change their notice and practices and if the terms do change, you may obtain a revised Notice by contacting Stable Transformation, LLC. by mail or by asking a therapist.
7. You have a right to file a complaint. If you believe that your privacy rights have been violated, you may file a complaint with (1) Stable Transformation, LLC or with (2) the Secretary of the Department of Health and Human Services. Both addresses are provided at the bottom of this form. All complaints must be submitted in writing. To file a complaint with Stable Transformation, contact the Office Manager. You will not be penalized for filing a complaint.
8. You have a right to provide an authorization for other uses and disclosures. Stable Transformation, LLC. will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. If you have any questions about this notice or our health information privacy practices, please contact Stable Transformation, LLC.
1208 17th Ave South
Nashville, TN 37212
Telephone: (615) 689-0191
US Dept. of Health and Human Services
200 Independence Ave., S.W.
Washington, DC, 20201
Telephone: (202) 619-0257
General Payment Policy: I understand that a deposit of half (50%) of the total program fee is due upon my completion of the registration form (or the signing of the letter of agreement in the case of teambuilding with professional organizations). I further understand that the program fee is to be paid in full at least 14 days prior to the first day of the program. Payment can be made with cash, check written out to Stable Transformation, or credit card via Square. I understand that I will be charged a $35 service charge on all returned checks.
Return Policy: I understand that if I cancel my participation in a Stable Transformation program more than 14 days before the program begins, Stable Transformation will refund my program fee in full. If I cancel more than 7 days but less than 14 days before the program begins, Stable Transformation will refund half (50%) of my program fee. If I cancel 7 days or less before the program begins or no show once the program begins, then I forfeit all of my program fee and Stable Transformation will not refund any portion of the fee. In the event that a program is canceled by Stable Transformation and unable to be rescheduled by Stable Transformation, you will be due a full refund of your paid program fee; however, you will be responsible for the costs associated with changes to any and all travel arrangements.
Charges for Phone Consultation: Appointments should be scheduled for extended conversations or questions. Brief consultations will not be charged so long as they are 15 minutes or less.
Consent for Release of Information: In some cases Stable Transformation, LLC may find it necessary, or may be required by law or rules governing your health insurance to communicate, bill, or facilitate claims processing. By signing this agreement you are granting release of information rights to Stable Transformation, LLC and staff to provide data necessary to process claims or facilitate receipt of payment.
Release of Medical Information to Clinical Contracts or Stable Transformation, LLC Clinical Employees: By signing this agreement you are granting full consent for release of information to any other Stable Transformation, LLC clinical personnel who may be involved in your care, treatment planning, equine therapy activities, or related clinical services. Signing this agreement also serves as consent to release information needed to file claims madeto insurance companies.
Privacy Policies: All sessions and their content, as well as the client’s records will be kept strictly confidential. To the extent possible, clients will be informed before confidential information is disclosed, and in that event only the essential information will be revealed. Clients may request restrictions on the uses or disclosures of Protected Health Information, with the exceptions listed below. Diagnosis may be made; if so, diagnosis becomes a part of the client records. The only times a client’s records may be shared without your consent are: 1) Client is in danger to self or others, 2) Therapist has knowledge of client being abused or neglected and/or 3) Disclosure is required by the court.
Emergency Policy: In the case of an emergency, go to the nearest Emergency Department or call 911.
HIPAA Notice of Receipt of Privacy Practices