I voluntarily consent and authorize CWI Physician Partners P.C., a California Professional Corporation; CWI Physician Partners P.C., a Hawaii Professional Corporation; CWI Physician Partners P.C., a Georgia Professional Corporation; CWI Physician Partners P.A., a Kansas Professional Association; CWI Physician Partners P.C., an Oregon Professional Corporation;  CWI Physician Partners P.C., a Nevada Professional Corporation, CWI Physician Partners P.C., a Rhode Island Professional Corporation;  CWI Physician Partners P.C., an Oklahoma Professional Corporation to review health history collection and evaluate for the purposes of a diagnostic screening test or determination for medical necessity related to equipment.  I understand that there are risks and benefits associated with utilizing equipment or undergoing a diagnostic screening testing, and there may be a potential for false positive or false negative test results. I assume complete and full responsibility to take appropriate action with regards to my test results.  Should I have question or concerns regarding my results, or a worsening of my condition, I shall promptly seek advice and treatment from an appropriate medical provider. I further acknowledge the following:

1. I am the individual who will provide the health history or sample for the Test(s).
   
   

2. I am at least eighteen (18) years of age.
   
   

3. I have read and understand the information provided about the Test(s) or equipment that I have been provided on the website where I requested the Test or equipment.
   
   

4. The information I have provided in connection with my request to CWI is correct to the best of my knowledge. I will not hold or its employees or agents responsible for any errors or omissions that I may have made in providing such information.
   
   

5. My health information and results may be shared with CWI employees and agents for the purpose of: ordering, processing, evaluating medical necessity, reporting of my results.
   
   

6. Medical Services provided by CWI are for the sole purpose of evaluating medical necessity or diagnostic assistance for one or more conditions, as diagnosed by a licensed medical provider.
   
   

7. I authorize CWI to contact me via text message to communicate with me regarding my test.
   
   

Patient Rights and Privacy Practices

1. Notice of Privacy Practices and Patient Rights: CWI Physician Partners P.C. Notice of Privacy Practices describes how it may use and disclose your protected health information for other purposes that are permitted or required by law.  To review a copy of CWI Physician Partners P.C. Notice of Privacy Practices, go to www.CynergyWellness.com.
   
   

2. Disclosure to Government Authorities: I acknowledge and agree that my test results and associated information may be disclosed to appropriate county, state, or other governmental and regulatory entities as may be permitted by law.
   
   

Release

1. To the fullest extent permitted by law, I hereby release, discharge and hold harmless, CWI including, without limitation, any its respective officers, directors, employees, representatives and agents from any and all claims, liability, and damages, of whatever kind or nature, arising out of or in connection with any act or omission relating to my diagnostic test, any and all use of medical equipment, or the disclosure of my test results.
   
   

By selecting the ACKNOWLEDGEMENT during the registration process, I acknowledge and agree that I have read, understand, and agreed to the statements contained within this form. I have read the contents of this form in its entirety and voluntarily consent to proceed.