For Healthcare Workers only
Address: 5189 W Woodmill Dr., Wilmington DE 19808. Website: www.HarmoniousMind.com
Tel: 302.633.6001 Fax: 302.295.6289 SMS/Text: 302.565.4818 Email: Support@HarmoniousMind.com
I hereby release, waive, covenant not to sue, and agree to hold harmless for any and all purposes sponsor, Harmonious Mind LLC, and its members, officers, agents, volunteers, or employees (“RELEASEES” or “INDEMNITEES”) from any and all liabilities, claims, demands, injuries (including death), or damages, including court costs and attorney’s fees and expenses, that may be sustained by me while participating in this activity, while traveling to and from the activity, or while on the premises owned, leased, or controlled by RELEASEES, including injuries sustained as a result of the sole, joint, or concurrent negligence, negligence per se, statutory fault, or strict liability of RELEASEES.
NOTE: Treatment is not conditioned by having to sign this consent. This information has been disclosed to the above-named recipient from records protected under Federal privacy regulations within the Health Insurance Portability and Accountability Act (HIPAA), 45 CFR parts 160 & 164. The information specified above will be disclosed pursuant to this authorization, and the recipient of the information may re-disclose the information, which may no longer be protected by the HIPAA privacy law. This consent is subject to revocation at any time except to the extent that action has been taken in reliance thereon. To revoke this consent, the request must be done in writing to: Support Staff or your therapist at Woodmill Corporate Center, Suite 30, Wilmington, DE 19808. If not previously revoked, this consent expires on date recorded below.
Your information will be encrypted.