Livara Health Medical Group, P.C., fka SpineZone Medical Fitness, Inc. (“Livara Health”) offers a variety of online programs, including an Online Fitness Program, a medically Supervised Track, and Medical Consultation. By participating in any of these programs, I provide my consent as follows:

Consent to Online Fitness Program

I consent to participation in the online fitness education and training program (the “Online Fitness Program”).

I acknowledge that as part of the Online Fitness Program, I may be engaging in physical exercises and using exercise equipment and, as with all such physical activity, there is an inherent risk of injury or complication to any pre-existing condition. I am voluntarily participating in these activities, and I knowingly and freely assume all risks of injury, loss or damage on account of these activities. I further agree that I am responsible for the condition and proper use of my personal exercise equipment and Livara Health is not liable for any injuries or damages related to equipment malfunctions or misuse. I understand that it is my responsibility to follow up on any issues identified in any self-assessments, including by following up with a medical provider as necessary.

I agree that I am responsible to ensure a safe and private environment for my participation in the Online Fitness Program. I acknowledge that the services provided in the Online Fitness Program will be provided over the internet and other electronic means, and that these online services (the “Online Services”) are subject to the disclosures and risks regarding the limitations of Online Services below.

Consent to Medically Supervised Home Exercise Program

Depending on my clinical needs, I may be placed in an Online Fitness Program track that is supervised by licensed clinical providers, who are typically medical doctors or physical therapists (collectively, “Medical Providers”). I understand that these Medical Providers may offer medical advice and supervision as necessary to administer my customized, supervised Online Fitness Program and Home Exercise Program (“Supervised Track”). If I am placed in a Supervised Track, I acknowledge and agree that my day-to-day interactions in the Online Fitness Program and training may be handled by non-licensed specialists engaged by Livara Health (collectively, “Coaches”), who may be athletic trainers, dieticians, mindfulness coordinators, health coaches, and other non-licensed support staff. Online Services in the Supervised Track will include online chats, video calls, and virtual evaluations.

I acknowledge that the Coaches will not offer independent medical advice. I further understand that my Coach’s advice, recommendations, and/or decisions may be based on factors not within the Coach’s control, including incomplete or inaccurate information provided by me. I understand that my Coach relies on information provided by me, and that I must provide any information I have received regarding any physical limitations I may have.

I understand that the Coach will consult with a Medical Provider in the event of any medical issues. In the event of any urgent medical questions, I agree to contact a licensed medical professional rather than Livara Health or any of its Coaches. I further understand that in the event of an emergency, I should immediately call “911” and request emergency care assistance rather than contact Livara Health or any of its Coaches.

Consent for Medical Treatment

Depending on my clinical needs, I may be eligible for consultation and treatment by a Medical Provider (a “Medical Consultation”).
I understand that my Medical Consultation treatment will be provided in accordance with recognized medical standards and clinical practice guidelines, but acknowledge that medicine is not an exact science and results are not guaranteed. I understand that I have the right to discuss the purposes and risks associated with all recommended treatment procedures and activities with my Medical Provider.

I further understand that my Medical Provider’s advice, recommendations, and/or decisions may be based on factors not within the Medical Provider’s control, including incomplete or inaccurate information provided by me. I understand that my Medical Provider relies on information provided by me, and that I must provide information about my medical history, condition(s), and current or previous medical care that is complete and accurate to the best of my ability.

In the event of an emergency, I understand that I should immediately call “911” and request emergency care assistance rather than contact a Livara Health Medical Provider.

Consent for Online Services & Telehealth

I understand I will receive education and training through Online Services, which may involve a combination of live and pre-recorded instruction. I acknowledge that in a Supervised Track or when receiving a Medical Consultation via telehealth, the Coach or Medical Provider interacting with me may not have the benefit of information that would be obtained through in-person evaluations, education, or training. Accordingly, my Coach or Medical Provider may not be fully aware of facts or other information that may affect the Coach’s opinion regarding a potential training recommendation for me or Medical Provider’s opinion regarding a potential clinical recommendation. I also understand that my Coach and/or the Medical Provider may determine in his/her sole discretion that my condition is not suitable for training using Online Services, and that I may need to seek in-person training or education from an alternative source.

I further understand that there are potential risks to the technology used for Online Services, including interruptions, unauthorized access, loss of information and delays in evaluation and training arising from technical difficulties and the potential inability of my Coach or Medical Provider to provide appropriate education and training via an online session. I understand that I can stop an online session at any time, for any reason, or stop using online sessions for fitness education and training. I understand that Livara Health can discontinue the Online Services if it is felt that the use of Online Services is not adequate for my situation. I understand that my Coach or Medical Provider may determine in his or her sole discretion that my condition is not suitable for online services, and that I may need to seek care from an alternative source.

I am also aware that in addition to my Coach or Medical Provider, other Livara Health staff members may be present during my online session. In addition, I may provide permission to record the session. I understand that I will be informed of the presence of any Livara Health staff members during the session, and will have the right to consent to their presence as part of the session. The authorized staff will at all times maintain the privacy and confidentiality of the information obtained pursuant to the online session.

Notice of Privacy Practices

I acknowledge that a copy of Livara Health’s Notice of Privacy Practices has been made available to me. Additional copies are available to me upon request.

Terms of Use

I acknowledge that a copy of Livara Health’s Terms of Use has been made available to me, and that I consent to the terms therein.

Release of Billing Information and Assignment of Insurance Benefits

Some of the services I receive may be billed to insurance. Where applicable, I request that payment of authorized insurance benefits be made on my behalf to Livara Health for any services furnished to me. I authorize any holder of medical information about me to be released to insurance companies, as well as any information necessary to pay any claim associated with my treatment.

Eligibility Guarantee

I agree that I must be eligible with my health insurance plan at the time of the appointment for insurance coverage to apply. I understand and agree that Livara Health will not take responsibility for the refusal of an insurance company to pay for training or other services due to lack of insurance benefits. If I am unable to provide insurance coverage at the time of the appointment, my appointment may be cancelled; if not, I will assume full financial responsibility for all charges incurred. In addition, should insurance eligibility status terminate retroactively, I will be financially responsible for any services provided that were billed to insurance.

Patient Health Plan Change

I agree to promptly inform Livara Health if my health plan changes to ensure I am not accruing additional expenses.

Common Interest

Kamshad Raiszadeh, MD holds an ownership interest in Livara Health.

As a patient, I understand that I have the right to choose another program or specialist if I seek spine rehabilitation, physical therapy, or medical care. If I choose another option for training or for clinical advice, I understand that I should contact my insurance company for assistance.

Patient Acknowledgement

I acknowledge that I have been informed regarding the Online Fitness Program, Supervised Track, and Medical Consultation, including the possible benefits, risks, and limitations of each. I acknowledge that I have been given the opportunity to ask questions regarding the Online Fitness Program, Supervised Track, and Medical Consultation, and my questions have been answered to my satisfaction. I certify that I have the legal capacity to execute this consent. I also certify that I have carefully read and consent to this Consent for Participation and Treatment. I agree that Livara Health shall not be liable for any injury, loss, or damage to personal property associated with my participation in the Online Fitness Program Supervised Track, and/or Medical Consultation.

I have carefully read and acknowledged the terms and conditions stated in the Livara Health Privacy Policy at https://livarahealth.com/privacy-policy/ and in the Livara Terms of Use Agreement athttps://livarahealth.com/terms-of-use/.

I understand that I may withdraw my consent to training and/or treatment at any time, except to the extent that Livara Health has already acted based on my consent, by providing Livara Health with written notice at support@livarahealth.com. Unless revoked earlier, this consent will remain valid for the duration of one (1) year (or shorter period if required by applicable state law), and will expire one (1) year from the date of my acknowledgement.