Membership Agreement/Waiver Form

Overview
I do hereby apply for membership in the Jay Warren PHA, hereafter termed “The Association,” a faith based private health association. With the signing of this membership agreement, I accept the offer made to become a member of The Association and have read and agree with the following Declaration of Purpose, Preamble and Memorandum of Understanding.

Declaration of Purpose:
The primary work of Jay Warren PHA is focused on educating and serving Jay Warren PHA members so that they have all the latest knowledge in providing protocols, including but not limited to Natural Healthcare, Holistic Healing Practices, Chiropractic, or any other natural form of healthcare practice to protect and improve the health of members. Secondary work includes, but is not limited to grassroots, political, and economic efforts to ensure the protection of our work.

Membership
By consenting to the Membership Agreement provided, members are granted the following rights and benefits:
Right to detailed informed consent about the services rendered, and what to expect.
Complaints against a Jay Warren PHA member must be submitted in writing to Jay Warren PHA within three months of the incident of complaint. These will be sent to the Person, Committee, or Tribunal designated by Jay Warren PHA for evaluation and remediation action.
Upon request, access to the Association’s Bylaws
Guarantee that all Personal Health Information (PHI) remain in the custody and in the confidential holding of Jay Warren PHA. Personal Health Information of all Members will be held in strict confidentiality and will remain private from any State Medical Board, the FDA, FTC, Medicare, Medicaid, or insurance companies without the previously expressed specific permission granted by the Member.
Membership with Jay Warren PHA will remain intact unless the member submits in writing their desire to withdraw membership or membership is terminated by The Association in accordance with bylaws.

Preamble
We believe that the First Amendment of the Constitution of the United States of America, and the Universal Declaration of Human Rights guarantees our members the rights of free speech, petition, assembly, and the right to gather for the lawful purpose of advising and helping one another in asserting our rights under international law, the Federal and State Constitutions and Statutes. IT IS HEREBY DECLARED that we are exercising our right of “freedom of association” as guaranteed by the 1st and 14th Amendments of the U.S. Constitution and equivalent provisions of the various State Constitutions, which are excepted out of the powers of general government. This means that our association activities are restricted to the private domain only.
We proclaim the freedom to choose for ourselves the types of products, services, therapies, and self-help modalities that we think best. We encourage our members to perform their own research by studying different resources to prevent illness, diseases of our minds and bodies, and for achieving and maintaining optimum wellness. We proclaim and reserve the right to include health options that include but are not limited to cutting edge treatment modalities and therapies practiced or used by any types of healers or therapists or practitioners the world over whether traditional or nontraditional, conventional, or unconventional.
Specifically, the mission of The Association is to change existing life and health circumstances through teaching alternative health awareness, which enables members to improve their physical well-being and to provide members with the highest-level services and of research and the most effective modalities for prevention. The Association will recognize any person (irrespective of age, race, creed, gender, sexual orientation or religion) who has been approved as a member and acts in accordance with these principles and policies as a member and will provide a medium through which its individual members may associate for actuating and bringing to fruition the purposes heretofore declared.

Memorandum of Understanding

I understand that members and service providers within The Association are not medical doctors.

I understand that within The Association no doctor-patient relationship exists but only a contract member-to-member association relationship. I have freely chosen to change my legal status as a public person or patient, customer, or client to a private member of The Association.
I understand that, since The Association is protected by the First and Fourteenth Amendments to the U.S. Constitution, it is outside the jurisdiction and authority of Federal and State Agencies and Authorities concerning any and all complaints or grievances against The Association, any Trustee(s), members or other staff persons. All rights of complaints or grievances will be settled by an Association designee, committee, or tribunal and will be waived by the member for the benefit of The Association and its members. By agreeing to this membership form, I agree that I have sought sufficient education to determine that this is the course of action I want to take for myself and my children.
Because the privacy and security of membership records maintained within The Association, which are held to be inviolate by the U.S. Supreme Court, the undersigned member waives HIPAA privacy rights and complaint process. However, any medical or healthcare records kept by members of The Association will be strictly protected and only released upon written request of myself as member.
I agree that violation of any waivers in this membership contract will result in a no contest legal proceeding against me.
The Association does not participate in any medical insurance plans or collections on behalf of the member but will provide a suitable invoice for the member to pursue reimbursement by his/her insurance company, if applicable.
Other aspects of informed consent will take place in my discussions with the providers and my fellow members of The Association.
As I am voluntarily choosing this method of natural health care, wellness, and disease prevention, I will not hold The Association or its members financially liable for any particular outcome regarding my health.
I agree to discuss my concerns with The Association members and to seek appropriate medical treatment, chiropractic or otherwise, should the need arise.

I agree to join the Jay Warren PHA, a private health membership association under common law, whose members seek to help each other achieve better health and good quality of life. My activities within The Association are a private matter that I refuse to share with the State Medical Board, the FDA, FTC, Medicare, Medicaid, or my own insurance company without my expressed specific permission. All records and documents remain as property of The Association, even if I receive a copy of them. I fully agree not to pursue any course of legal action against a fellow member of The Association, unless that member has exposed me to a clear and present danger of substantive evil, and upon the recommendation and approval of The Association.
I enter into this agreement of my own free will without any pressure or promise of cure or disease prevention. I affirm that I do not, or will not, as a private member represent any Local, State or Federal agency whose purpose is to regulate and approve products, or to carry out any mission of enforcement, entrapment or investigation and agree to accept membership in the capacity of private member. I have read and understood this document, and my questions have been answered fully to my satisfaction. I understand that I can withdraw from this agreement and terminate my membership in this association at any time, and that my membership can and will be revoked if I engage in abusive, violent, menacing, destructive or harassing behavior towards any other member of The Association. These pages consist of the entire agreement for my membership in The Association.

Payment of any dues, fees or program costs, if applicable and delivery of these signed documents to an Association representative is considered sufficient for my one-time membership contract. Term begins with the date of submission of this contract.