Agreement for Wellness Services

 

AgreementforWellnessServices-2017

 

Practitioner Information
Name*
 
PMA License
Email*
Street Address*
City*
   
Phone*
Practitioner Signature (type your name)*
Client Information
Name*
 
Email
Street Address*
City, State, Zip*
 
Phone
Client Signature (type your name)*
If you do not have an email address, please provide the name of someone authorized to communicate by email on your behalf to whom we can send a copy of this Agreement.

Name of Person Authorized to Receive/Send Email on Client's Behalf
The Person's Email Address
Phone

Please leave this field empty.

    How to Use This Form

    This online facility is provided to help PMA Practitioners and their clients enter into the Agreement for Wellness Services.  By completing the above form and following the procedure  involving an exchange of emails, the AWS is effectively signed and becomes binding upon both parties and a record of the transaction is created in PMA’s database.

    For your protection, even if you are printing out and signing the AWS physically with your clients, you should complete and submit the above form to create a record in the PMA’s database of entering the Agreement with your clients and subscribing your clients to the PMA Health Network as provided in the AWS.

    Paragraph 18 of the AWS outlines the procedure to which the parties agree for signing the Agreement using the above form.  Here is how it works.

    When you enter and submit the names and contact information in the form above, the system automatically sends a “Confirmation Email” to the PMA Practitioner and the Client to the email addresses you have provided. If the Client does not have or use email, the system will send the Confirmation Email to the person you identify as being authorized to receive and send email on behalf of the Client.

    For reference, you can Click Here to View a Sample Confirmation Email. Obviously, it is important to be careful when entering the email addresses of the parties to the AWS in the form above to be sure the addresses are written correctly.

    The first section of the Confirmation Email presents the names and contact information of the PMA Practitioner and Client exactly as you have entered that information in the form above.  If you have provided the name, phone number and email address of a person authorized to receive / send email on behalf of the Client, that information is included as well.

    Additional sections of the Confirmation Email present “INSTRUCTIONS TO CLIENT“, “INSTRUCTIONS TO CLIENT’S AUTHORIZED AGENT” and “INSTRUCTIONS TO PRACTITIONER” about what to do next to complete the AWS signing process.

    Basically, the Client or Client’s agent are instructed to (1) print and keep copies of the Confirmation Email and AWS, and (2) send an email to the PMA Practitioner confirming receipt of the Confirmation Email. And the Practitioner is similarly instructed to retain copies of the Confirmation Email as part of his / her Client records, as well as a copy of the email received from the Client or Client’s agent acknowledging receipt of the Confirmation Email. The Practitioner is further advised to contact the Client or Client’s agent if the Practitioner has not received email notice that the Client in fact received the Confirmation Email.

    Note that Paragraph 18 of the AWS refers to your “Practice Disclosure”, which is a written statement you should give to your client describing “the Practitioner’s education, training and experience in the services to be provided” (see Paragraph 2 of the AWS) at the time you enter into the Agreement. Delivering your Practice Disclosure will also be accomplished by the use of the above form in the near future. In the meantime, you should deliver your written Practice Disclosure to your clients directly.

    Please feel free to Contact Us if you have further questions about how to use this form.