USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION 
I consent to allow Boston Bone Density Center and/or DexaFit Boston to use their DXA scanner to perform a body composition and/or bone densitometry scan, with full awareness that the technology uses low-dose x-rays. 

RECORDS REVIEW FOR RESEARCH 
I also authorize Boston Bone Density Center and/or Dexafit Boston to use or review my de-identified records for research purposes and/or to determine my qualifications for approved clinical studies and to contact me if I have potential as a research candidate. 

FINANCIAL RESPONSIBILITY 
I accept financial responsibility for all charges for services provided to me and/or my family members. 

WAIVER AND AGREEMENT 
1. I do hereby release all representatives of Boston Bone Density Center and/or Dexafit Boston that are acting upon their behalf from any responsibility or liability for any injury or damage to myself, including those caused by the negligent act or omission of any of those mentioned or others acting on their behalf or in any way arising out of or connected with my participation in services, activities, or programs of Boston Bone Density Center and/or Dexafit Boston.
 
2. I am voluntarily participating in the Boston Bone Density Center and/or Dexafit Boston DXA scan service and/or other including 3D scan, RMR and VO2max Metabolic Analysis. I hereby agree to expressly assume any and all risks of injury and death resulting from participation in the aforementioned services. 

3. I further hereby declare myself to be physically sound and suffering from no condition, impairment, disease, infirmity, or other illness that disqualifies me from receiving a DXA scan from Boston Bone Density Center and/or Dexafit Boston I acknowledge that I have permission to participate or that I have decided to participate in these services without the approval of my physician and do hereby assume all responsibility for my participation.  I also certify that I am not pregnant or trying to become pregnant.   
       
4. I take full responsibility for any action taken by me after my visit to Boston Bone Density Center and/or Dexafit Boston I do not hold any representatives of Boston Bone Density Center and/or Dexafit Boston Inc responsible or liable for any adverse effects or complications arising from the services or opinions offered by them. 

5. Confidentiality. The information based on the observations made during the DXA scan, VO2max, or RMR analysis, and subsequent report is treated as privileged and confidential. However, it may be used for statistical or scientific purposes with your right to privacy retained. 

6. I understand that Boston Bone Density Center and/or Dexafit Boston does not diagnose or interpret the DXA results, and that any further review or analysis of the report is between the individual and their primary care physician. 

CLIENT HIPAA CONSENT FORM 
‘I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize Boston Bone Density Center and/or Dexafit Boston to use and disclose my protected health information to carry out: 

Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment); 
Obtaining payment from third party payers (e.g. my insurance company); 
The day-to-day operations of Boston Bone Density Center and/or Dexafit Boston practice. 

I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment and health care operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are then bound to comply with this restriction. 

I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent is not affected. 

AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION 
I hereby authorize Boston Bone Density Center and/or Dexafit Boston to forward the health and fitness information resulting from their services to me or any parties authorized by me by means of email, fax, mail, or through the private login page on the Boston Bone Density Center and/or Dexafit Boston website. I also understand that this Authorization 
is subject to revocation/withdrawal by me at any time in writing to Boston Bone Density Center and/or Dexafit Boston , except to the extent that the action has already been taken to release this information. This Authorization shall remain valid unless revokedBoston Bone Density Center and/or Dexafit Boston will not forward my health and fitness information if I do not consent to this Authorization.