Membership Application

BioStar Organix Healthcare Association

A Private Medical Membership Association 

Lifetime Membership Agreement

 

For:

 

Membership provides a freedom in building your individualize healthcare program, and allows constructive team work between members.  Each program is customized based on your biological preference report or just simple observations. Since man existed it’s known that food and water is essential to sustain the human body.  Food is your first medicine and the holistic arts field attends to the body, mind and soul with equal importance.

 

Since food is key to a better health, it is recommended that you begin with the

*Blood Type Food List, before starting any dietary supplementation program.

     Download your free food list at http://www.biostar-health.org

*Based on naturopath Peter J. D'Adamo, N.D., in his book Eat Right 4 Your Type.      

 

Summary of Fees and Special Assessments

Sessions are approximately one hour, which includes a pre-talk, and post talk.

Dietary Supplements

Online Health Products Store

DIACOM Health Analysis Report

ZYTO Biological Preference Report 

ACUGRAPH Meridian Measurement 

EVOX or Hypnosis Therapy

Hypnosis/Chakra Meditation

Standard office visit

Couples office visit

Member’s children

Priority Appointments

Referral by Member

Direct email/text message support

After hours visits

Latest Research and News

• Exclusive to members of the association

https://www.biostarorganix.com

• $150 Detailed use + Office Visit

• $150 Detailed use + Office Visit

• $150 Detailed use + Office Visit

• $90 1 hour ($120 over 1-hour)

• $90 1 hour ($120 over 1-hour)

• $60 45 min. ($80 full hour)

• $120 45 min. ($160  full hour)

• Free consultation under 13 years

• Must use http://www.biostarLA.com

• 30 Min. Free Consultation (New/Member)

• Included for non-urgent needs

• Included for non-emergency needs

• Included at http://www.biostar-health.org

 

BioStar Organix Healthcare Association

A Private Medical Membership Association

4443 West Sunset Blvd., Ste. “B” Los Angeles, CA 90027

Phone (323) 698-8777  Fax (323) 665-2498


 

Classical Naturopathy

 

A classical naturopath specializes in wellness. That is to say teaching clients how applying natural lifestyle approaches can act to facilitate the body’s healing and health building potential. The classical naturopath does not undertake to diagnose or treat disease but recognizes that the majority of sub-health conditions are cumulative effects. Also the underlying cause of disease is improper diet, unhealthy habits and environmental factors that cause biological imbalances leading to a weakening of the body’s defenses and subsequent breakdown in health. The practice of classical naturopathy is not considered the practice of medicine and is legal in all 50 states; however, some states have made naturopathy illegal unless licensed. This is because legislature is grouping classical naturopaths with naturopathic physicians. Naturopathic physicians have a 4-year degree that includes pharmacology and minor surgery, which should require a license.

 

The practice of classical naturopathy is recognized as a common occupation at the federal level (U. S. Congress 1928, 1929, 1930 and 30 Federal Court rulings between 1958 and 1978) and in such a profession is protected under the 14th and 9th Amendments of the U. S. Constitution. Several states have also made this stipulation either by statute or in the Courts.

 

All disease is one and what medical doctors call diseases are only symptoms of a greater underlying problem. Disease is nothing more than a manifestation of our body trying to correct imbalances. Imbalances due to faulty nutritional patterns, improper rest, stress management and other lifestyle considerations, which over time, result in a weakening of the body. By the time disease appears on the scene it is very late in the game.

 

Our body tells us early on when there is a problem and we can either respond to this message or try to suppress the symptoms that the body uses to tell us there is a problem. You can take ibuprofen or other drugs to suppress the symptoms and they will help for a short time. However, unless the underlying problem is corrected, eventually the symptoms will no longer be helped by these drugs and one will need to take stronger and stronger drugs to quiet the body’s message. If the underlying problem has not been addressed, the body will begin to break down structurally. At this time modern medicine is finally capable of diagnosing that something is really wrong and offer interventions to fix the structure, but still medical doctors fail to address the underlying problem.

 

Naturopathy concentrates on identifying destructive aspects in lifestyles that lead to imbalances. Before symptoms manifest and long before a diagnosis can be rendered, these destructive aspects of our lifestyle can be identified and corrected. Once corrected, the body automatically corrects itself. Diagnosing disease and illness is totally unnecessary to correcting the underlying problems that result in disease and illness. A true healer does not waste his time concentrating on naming diseases but rather on identifying those underlying factors that if not addressed result in the manifestation of disease and illness. These factors can be identified and corrected long before it is even possible to make any diagnosis. Even after a diagnosis is made the same concepts of healing used by classical naturopaths are equally effective because once balance is restored the body automatically heals itself.

 

Since relaxation is key to a better health, it is highly recommended

that you try self-meditation a few times prior to your appointment.

     Download a Free MP3 meditation at http://uThinkWell.com/

HOW TO OBTAIN CURRENT TERMS A CONDITIONS, REFUND POLICIES

 

 

Terms and Conditions. Additional terms and conditions may apply to certain purchases and visits, please visit https://www.biostarorganix.com/tos for the latest information as they may change without notice.

 

Purchases:Each time you make a purchase, the terms and conditions must be checked and accepted upon checkout before releasing the chosen service, products, or other.  The acceptance of terms and conditions deems notification to member of all referred change(s) and/or notification(s). 

 

Services: The services provided by BioStar Organix Healthcare Association are highly speculative in nature, and we do not guarantee that the results of our work will be satisfactory to a member. We reserve the right to refuse service to anyone. Due to time sensitive concerns or other expenses most of our practitioners incurred to offer this service, no refunds are available for appointment visit(s). BioStar Organix Healthcare Association has the right to refuse service and refund the money for the following reasons:

 

  • A practitioner changes/cancels date of appointment.

 

  • A practitioner considers unable to perform services for any reason.

 

 

  • A practitioner considers subject (member) unwilling to cooperate causing creating a conflict of interest.

 

  • If a member show disruptive behavior as to cause or endanger the safety of practitioner, staff, or others.

 

A consultation is fully completed when:

 

  • A session has gone on for thirty (30) minutes.

 

Non-Refundable: All products requiring refrigerated storage or any heat-sensitive items. Any unsealed or opened product.  Box opened or damage.  Missing box or damaged equipment, product or unit.  Any special-orders or special product requested for another member.  

 

Product Return Policy: Undamaged, Sealed/Unopened products returned within 5 days of purchase. After 5 days to a maximum of 30 days, refunds are made in the form of store credit – applied towards future session fees only. No refunds or credit after 30 days.

 

 

 

 

 

 

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Consumer Disclosure Regarding Conducting business electronically,

Receiving Electronic Notices and Disclosures, and Signing Documents Electronically

Please read the following information, by proceeding forward and signing this document you are agreeing that you have reviewed the following consumer disclosure information and consent to transact business using electronic communications, to receive notices and disclosures electronically, and to utilize electronic signatures in lieu of using paper documents. This electronic signature service is provided on behalf of members, “sending party,” whom are sending electronic documents, notices, disclosures or requesting electronic signatures to you.

  • You are not required to receive notices and disclosures or sign documents electronically. If you prefer not to do so, you may request to receive paper copies and withdraw your consent at any time as described below.

Paper CopiesYou are not required to receive notices or disclosures or sign documents electronically and may request paper copies of documents or disclosures if you prefer to do so. You also have the ability to download and print any open or signed documents sent to you through the BioStar Organix electronic signature system using the PDF and Print icons. BioStar Organix may also email you a PDF copy of all agreement you sign using the BioStar Organix service(s). If you wish to receive paper copies in lieu of electronic documents you may request paper copies from the “sending party” by following the procedures outlined below. The “sending party” may apply a charge for requesting paper copies. Use of the Service requires a standards-compliant web-browser, which supports the HTTPS protocol, HTML, and cookies. Viewing PDF documents requiring additional software such as Adobe Reader or similar.

Withdrawal of Consent - You may withdraw your consent to receive electronic documents, notices or disclosures at any time. In order to withdraw consent you must notify the “sending party” that you wish to withdraw consent and to provide your future documents, notices, and disclosures in paper format. After withdrawing consent if at any point in the future you proceed forward and utilize the electronic signature system you are once again consenting to receive notices, disclosure, or documents electronically. You may withdraw consent to receive electronic notices and disclosures and optionally electronically signatures by following the procedures described below.

Scope of Consent - You agree to receive electronic notices, disclosures, and electronic signature documents with all related and identified documents and disclosures provided over the course of your relationship with the “sending party.” You may at any point withdraw you consent by following the procedures described below.

Requesting paper copies, withdrawing consent, and updating contact information

You have the ability to download and print any documents we send to you through the electronic signature system. To request paper copies of documents, withdraw consent to conduct business electronically and receive documents, notices, or disclosures electronically or sign documents electronically please contact the “sending party” by telephone, postal mail, or by sending an email to the “sending party” with the following subjects:

  • “Requesting Paper Copies” Please provide your name, email, telephone number, and postal address and document title.
  • “Withdraw Consent” Please provide your name, email, date, telephone number, postal address.
  • “Update Contact Information” Please pro­­vide your name, email, telephone number and postal address.

Any fees associated with requesting paper copies or withdrawing consent will be determined by the “requesting party.”

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BioStar Organix Healthcare Association

 (A Private Medical Membership Association)

MEMBERSHIP CONTRACT

 

I, _________________________________________, for membership fee paid in hand, do hereby apply for membership in BioStar Organix Healthcare, a private membership organization.  With the signing of this membership agreement I/we accept the offer made to become a member of BioStar Organix Healthcare Association of Los Angeles, California, USA and have read and agree with the following Declaration of Purpose from Article I of BioStar Organix Healthcare Articles of Association.

 

1.     This Association of members hereby declares that our main objective is to maintain and improve the civil rights, constitutional guarantees, and political freedom of every member and citizen of the United States of America.  We believe that the Constitution of the United States is one of the best documents ever devised by man, and the signers of the Declaration of Independence did so out of love for their country.

 

2.         As members, we affirm our belief that the Constitution of the United States is one of the best documents ever devised by man and the signer of the Declaration of Independence did so out of love for their country. We believe that the First Amendment of the Constitution of the United States of America guarantees our members the rights of free speech, petition, assembly, and the right to gather together for the lawful purpose of advising and helping one another in asserting our rights under the Federal and State Constitutions and Statutes. We strive to maintain and improve the civil rights, constitutional guarantees, freedom of choice in health care and political freedom of every member and citizen of the United States of America. 

 

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.  This means that our association activities are restricted to the private domain only.

 

3.     We declare the basic right of all of our members to select spokesmen from our number who could be expected to give wisest counsel and advice concerning the need for physical and mental health care assistance and to select from our number those members who are the most skilled to assist and facilitate the actual performance and delivery of therapy, treatment and care.

 

4.     We proclaim the freedom to choose and perform for ourselves the types of therapies and treatment modalities that we think best for diagnosing, treating and preventing illness and disease of our minds and bodies and for achieving and maintaining optimum wellness.  We proclaim and reserve the right to include medical and 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. 

 

 

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5.     More specifically, the mission of our Association is to provide members with the highest level of quality care and the most effective methods of treatment.  We treat members and their health and medical condition, and not merely the symptoms experienced.  Our Association understands that wellness has many dimensions and strives every day to stay on the leading edge of new technology.  The Association provides comprehensive, conventional, complementary alternative care and the most advanced technologies to diagnose all aspects of a member’s disease and provide the most effective means of treatment at an affordable fee.  More specifically, the Association specializes in, but not limited to, Hypnosis and Meditation, Bio- resonance Analysis of Health (or B.A.H. for short) is a multi-faceted and comprehensive diagnostic method. It can be used to evaluate all aspects of an individual’s health, identify all dysfunctions, and create a unique program of treatment that best suits the individual patient. Bio-resonance Analysis of Health will allow our practitioners to precisely determine what vitamins, supplements, remedies, and procedures are the most effective in the treatment of the individual person. This system also allows for great detail - from dosage, to duration, and even the time of day that would most benefit the patient. Additionally, the Association specializes in diets, hypnosis treatments for cancer, addiction, emotional stress, spiritual counseling, marriage, addiction, behavioral modification and regression, education.  The Association utilizes electronic biofeedback, digital meridian testing, ionic and micro-frequency stimulation (for parasites and microbiological organisms, heavy metal detoxification), live/dry blood analysis, audio and video recording, photography of the face, eyes, ears, hands and live and dry blood, magnets, moxa, various essential oils for pain and emotional balance, massage, reflexology, and light touch, hyperbaric oxygen chambers, far infrared sauna, heat pads and foot baths for detoxification as alternates to medication concerning the modalities of service and benefits to members.

 

6.     The Association will recognize any person (irrespective of race, color, or religion) who is 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 the fellow members of the Association that provides services and care, do so in the capacity of a fellow member and not in the capacity as a licensed health care provider.  I further understand that within the association no doctor-patient relationship exists but only a contract member-member Association relationship.  In addition, I have freely chosen to change my legal status as a public patient, customer or member to a private member of the Association. I further understand that it is entirely my own responsibility to consider the advice and recommendations offered to me by my fellow members and to educate myself as to the efficacy, risks, and desirability of same and the acceptance of the offered or recommended diagnosis, therapy, treatment and care is my own carefully considered decision.  Any request by me to a fellow member to assist me or provide me with the aforementioned diagnosis, therapy, treatment and care is my own free decision in an exercise of my rights and made by me for my benefit, and I agree to hold the Trustee(s), staff and other worker members and the Association harmless from any unintentional liability for the results of such care, except for harm that results from instances of a clear and present danger of substantive evil as determined by the Association, as stated and defined by the United States Supreme Court.

Initials ________

The Trustees and members have chosen Ulysses L. Angulo as the person best qualified to perform services to members of the Association and entrust him to select other members to assist him in carrying out that service.

 

In addition, 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 Committee and will be waived by the member for the benefit of the Association and its members. Because the privacy and security of membership records maintained within the Association which have been held to be inviolate by the U.S. Supreme Court, the undersigned member waives HIPAA privacy rights and complaint process.  Any medical or healthcare records kept by the association will be strictly protected and only released upon written request of the member.  I agree that violation of any waivers in this membership contract will result in a no contest legal proceeding against me.  In addition, 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.

 

I agree to join the Association, a private membership association under common law, whose members seek to help each other achieve better health and live longer with good quality of life.

 

I understand that the doctors, nurses, and other providers who are fellow members of the Association are offering me advice, services, and benefits that do not necessarily conform to conventional medical care.  I do not expect these benefits to include on-call coverage, hospital care, or the usual and customary care provided by most physicians.  I will receive such primary and specialist care elsewhere.  I fully understand that the benefits I receive from the Association might or might not be covered by my health insurance and not at all by Medicare.

 

As a member, I accept the goals of helping my body function better and choosing techniques that are both very safe and have a reasonably good chance to succeed, realizing that no diagnostic technique or treatment is foolproof.  If I choose to forgo drugs, surgery, or radiation that has been recommended to me by others, I fully accept the risk that I might suffer serious consequences from that choice.  Other aspects of informed consent will take place in my discussions with the providers and my fellow members of the Association.

 

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 file a malpractice lawsuit against a fellow member of the Association, unless that member has exposed me to a clear and present danger of substantive evil.  I acknowledge that the members of the Association do not carry malpractice insurance.

 

 

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Patient Disclosure for California Senate Bill SB-577 Compliance

 

I, Ulysses Angulo, am a Certified Natural Health Practitioner (CNHP), Consulting Hypnotist and Healing Arts Practitioner. I am not a physician; I am not licensed by the state as a healing arts practitioner and may not provide a medical diagnosis nor recommend discontinuance of medically prescribed treatments. In order to use my services, California state law requires that you acknowledge receipt of the information provided in this form and that you sign it, keep a copy for yourself, and that I keep the one you give me for at least three years.

 

My method of service: In “holistic art nutrition and classic naturopathy” an alternative or complementary to healing arts that are licensed by the State of California. Under Sections 2053.5 and 2053.6 of California’s Business and Professions Code, I can offer you these services, subject to requirements and restrictions that are described fully on your membership contract. The idea behind “holistic arts nutrition and classic naturopathy” is as follows:

  • Holistic Arts Nutrition is the practice of correcting imbalances that cause disease and boosting the digestive and immune system by providing the body with optimal amounts of substances that are natural to the body.
  • Classic Naturopathy is an "alternative“ or "complementary" educational approach to health and wellness which focuses on achieving the appropriate balance required for optimal health in the areas of: lifestyle (diet & nutrition, physical fitness, etc.), mental well-being (stress reduction, healthy relationships, etc.), and spirituality (religious beliefs, personal philosophies, character development).  (See pg. 2  for more details.)

 

Redress: If a member desires a diagnosis or any other type of treatment from a licensed professional, the member may seek such services at any time. In the event a member terminates their services, the member has a right to coordinated transfer of services to another practitioner. A member has a right to refuse healthcare or hypnosis services at any time. A member has a right to be free of physical, verbal or sexual abuse. A member has a right to know the expected duration of treatment, and may assert any right without retaliation. In the event you are not satisfied with my services I request that you speak to me promptly and personally about your concerns.

 

My Approach: The member is educated to view the self as one or a "whole being," hence the name. As a practitioner of holistic clinical nutrition, and holistic patient education, I will provide you with personal consultations that are educational in nature. They will be based on your personal needs and unique profile. I may inform you about the proper scheduling of certain dietary vitamins, minerals, herbs, or other supplements, and teach you about how certain changes to your lifestyle or outlook may improve your health and wellness. I may show you certain self-assessment techniques such as use of blood tests, pressure cuff or to palpate (feel) yourself for tenderness in various points. I may also demonstrate blood testing, muscle strength testing, use of self-hypnosis, and use of biofeedback also known as “energy testing” systems (e.g. DIACOM, ZYTO or ACUGRAPH).

 

Contact Information: phone (323) 698-8777, fax (323)665-2498, email: orders@biostarorganix.com

 

 

 

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Special Assessments / Fees: The standard charge for my services is $120 per session. 24-hours advance cancellation notice is kindly requested. I accept most credit cards. I will provide you with the documentation you need to bill your insurance company if they cover the cost of my services, although most unlikely. See Special Assessments on page 1.

 

Audio/Video Recording: All Hypnosis services are recorded, at no charge to the member. Any audio recording of a hypnosis session is a gratuity and is not part of the hypnosis fee. We do not guarantee that the tape will be audible, fully intact or usable. We will not be responsible for nor issue refunds for defective or damaged tapes.

 

Warranty: No Warranty is given, expressed or implied for specific results from Spiritual Counseling / Health consultations or Hypnosis session(s).

 

Confidentiality: I will not release any information to anyone without a written authorization from you, except as provided for by law. You have a right to be allowed access to my written record about you.

 

Number of Consultation Sessions: The number of sessions generally will vary from a minimum of two to several visits depending upon the behavior modification desired. Sessions are designed with the member to meet individual needs. Please be informed that I do not treat emotional, medical or psychological disorders but use verbal directions while you are relaxed to guide you in meeting your stated goals.

 

If you ever have any concerns about the nature of my education, please feel free to discuss them with me.

My training and education is described below:

  • I have been certified as a Natural Health Specialist (CNHP) from the Trinity School of Natural Health – http://trinityschool.org/
  • I have been certified as a Fellow at the Institute of Human Individuality http://www.generativemedicine.org/ifhi/
  • I have received training in Live/Dry Microscopy, Finger Nail and Tongue Analyst, Aromatherapy. http://www.cnhp.org/  http://www.chi-health.com
  • I am trained in hypnotherapy and with certification from the Sylvia Browne Hypnosis Training Center. As the state of California has not adopted educational and training standards for the practice of hypnotherapy, this statement of credentials is for informational purposes only.  http://www.sylviabrownehypnosis.org/
  • I have been ordained as a Minster from Universal Life Church and confer members with spirituality (e.g. Gnostic Christianity from Novus Spiritus http://novus.org.)

 

Hypnosis Methods Used: The Hypnotist employs Spiritual Counseling and hypnosis techniques to facilitate the member’s quest for self- improvement. Specific techniques may include but is not limited to: Spiritual Philosophy, Body Relaxation, Directed Meditation, Age Regression, Cell Memory, Past-Life Regression, and/ or Behavior Modification.

 

 

 

 

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When signing this membership agreement you acknowledge and understand that California has specific laws pertaining to the use of hypnosis to enhance or recover memories to aid in testifying in criminal matters and that those laws may also impact civil cases if the hypnosis is used for the same purposes. Use of hypnosis to aid memory or recall for court testimony may result in the inadmissibility of that testimony. I advise you to contact your attorney if and questions exists in your mind as to whether you may effect legal rights in matters currently pending by the use of hypnosis.

 

Forensic Hypnosis: By signing below you are agreeing that you are not currently involved in any criminal or civil matters where you are seeking to enhance or develop memories for use in litigation. Member agrees to hold the hypnotherapist harmless, to defend and indemnify the hypnotherapist from any claims, including all attorneys' fees and costs related to the so-called creation of memories or testimony that may arise or be related.

 

State law requires that I recommend that you inform your medical doctor that you are receiving “holistic arts services and classic naturopathic education”. Please remember that doctor, nutritionists, herbalists, and other medical professionals and health practitioners hold widely varying views. I intend to offer health information to help you cooperate with a competent medical doctor (MD) in your mutual quest for health. In the event you use this information without your medical doctor’s (MD’s) approval, you prescribe for yourself – then Ulysses Angulo and members of BioStar Organix Healthcare Association assumes no responsibility.

 

 

Patient Disclosure for California Senate Bill SB-577 Compliance

 

Acknowledgement and Consent to Receive Services Statement:

 

I agree and understand, the above disclosure about the holistic arts and clinical nutrition, and the holistic arts services and classic naturopathic education offered by Ulysses Angulo including his training and education. I have discussed with Ulysses Angulo the nature of the services to be provided. I understand that Ulysses Angulo is not licensed by the state as a healing arts practitioner, or hypnotist or any other service of the Association. I understand it is my responsibility to maintain a relationship for myself/my child with a medical doctor. I have consented to use the services offered by Ulysses Angulo or members of BioStar Organix Healthcare Association, and agree to be personally responsible for the fees of BioStar Organix Healthcare Association in connection with the services provided to me. I understand I may not receive any insurance reimbursement or a tax deduction for these services.

 

 

 

 

 

 

 

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(For more information visit: http://www.californiahealthfreedom.com)

The foregoing is true and correct to the best of my knowledge and I agree to be bound by my own representation.

 

I enter into this agreement of my own free will or on behalf of my dependent without any pressure or promise of cure.  I affirm that I do not represent any State or Federal agency whose purpose is to regulate and approve products.  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.  These pages and Article I of the articles of association of the Association consist of the entire agreement for my membership in the Association and they supersede any previous agreement.

 

I understand that the membership fee entitles me to receive those benefits declared by the Trustee(s) to be “general benefits” free of further charge.  I agree to pay as levied those benefits that I receive that are declared by the Trustees to be “special assessments”, per Fee Schedule. I fully understand and I agree with it and to do business electronically with BioStar Organix Healthcare and agree that I have reviewed the consumer disclosures related to electronic signatures.

 

I enclose the sum of $_____.00 as consideration for my lifetime membership contract, said term beginning with the date of the signing of this contract, and by these presents do hereby certify, attest and warrant that I have carefully read the above and foregoing BioStar Organix Healthcare’s Contractual Application for Membership, and I fully understand and agree with same.

 

IN WITNESS WHEREOF,

 

(Print) Name:

 

 

_________________________ / _______________________

 

Member                                      Parent or Legal Guardian

 

I have read and received an electronic copy of this agreement.

 

 Member

Signature: X                                                                                      Date: 

 

Indicate capacity to sign if other than (Self):   ____Parent   ____Guardian

 

BioStar Organix Healthcare Association:     

Membership via: __Online  __In-person

Invoice#:

Approved By:____________________________

Payment: $

  Date:                                20____ 

 

Confidential Member Information Form

 

 

First Name: ___________________ Last Name:________________________

 

Address: _______________________________________________________

 

City: _________________________ State:_______     Zip Code:___________

 

Cell Phone: (_____) ____________--__________________

 

Email: ______________________ @ __________________

 

Occupation: _____________________ DOB: _________ Birth Time: _______

 

Blood Type:                                            Referred by:

 

Are you currently under the care of a doctor or psychologist?

 

NO____ YES_____

lf yes, please explain________________________________________________

 

Do you have any past medical conditions or psychological history that the practitioner should be aware of before the session?

 

NO____ YES_____

lf yes, please explain________________________________________________

 

Did you notify your qualified medical physician that you are working with a Holistic Arts Practitioner?  YES____ NO_____ N/A _____

 

Optional - Have you ever been hypnotized and/or regressed?

NO ___ YES______  

lf yes, please explain________________________________________________

 

________________________________________________________________

 

What do you want to accomplish or let your practitioner know?

 

 

 

 

 

 

 

Lifetime Membership Agreement

 

For:

 

Membership provides a freedom in building your individualize healthcare program, and allows constructive team work between members.  Each program is customized based on your biological preference report or just simple observations. Since man existed it’s known that food and water is essential to sustain the human body.  Food is your first medicine and the holistic arts field attends to the body, mind and soul with equal importance.

 

Since food is key to a better health, it is recommended that you begin with the

*Blood Type Food List, before starting any dietary supplementation program.

     Download your free food list at http://www.biostar-health.org

*Based on naturopath Peter J. D'Adamo, N.D., in his book Eat Right 4 Your Type.      

 

Summary of Fees and Special Assessments

Sessions are approximately one hour, which includes a pre-talk, and post talk.

Dietary Supplements

Online Health Products Store

DIACOM Health Analysis Report

ZYTO Biological Preference Report 

ACUGRAPH Meridian Measurement 

EVOX or Hypnosis Therapy

Hypnosis/Chakra Meditation

Standard office visit

Couples office visit

Member’s children

Priority Appointments

Referral by Member

Direct email/text message support

After hours visits

Latest Research and News

• Exclusive to members of the association

https://www.biostarorganix.com

• $150 Detailed use + Office Visit

• $150 Detailed use + Office Visit

• $150 Detailed use + Office Visit

• $90 1 hour ($120 over 1-hour)

• $90 1 hour ($120 over 1-hour)

• $60 45 min. ($80 full hour)

• $120 45 min. ($160  full hour)

• Free consultation under 13 years

• Must use http://www.biostarLA.com

• 30 Min. Free Consultation (New/Member)

• Included for non-urgent needs

• Included for non-emergency needs

• Included at http://www.biostar-health.org

 

BioStar Organix Healthcare Association

A Private Medical Membership Association

4443 West Sunset Blvd., Ste. “B” Los Angeles, CA 90027

Phone (323) 698-8777  Fax (323) 665-2498


 

Classical Naturopathy

 

A classical naturopath specializes in wellness. That is to say teaching clients how applying natural lifestyle approaches can act to facilitate the body’s healing and health building potential. The classical naturopath does not undertake to diagnose or treat disease but recognizes that the majority of sub-health conditions are cumulative effects. Also the underlying cause of disease is improper diet, unhealthy habits and environmental factors that cause biological imbalances leading to a weakening of the body’s defenses and subsequent breakdown in health. The practice of classical naturopathy is not considered the practice of medicine and is legal in all 50 states; however, some states have made naturopathy illegal unless licensed. This is because legislature is grouping classical naturopaths with naturopathic physicians. Naturopathic physicians have a 4-year degree that includes pharmacology and minor surgery, which should require a license.

 

The practice of classical naturopathy is recognized as a common occupation at the federal level (U. S. Congress 1928, 1929, 1930 and 30 Federal Court rulings between 1958 and 1978) and in such a profession is protected under the 14th and 9th Amendments of the U. S. Constitution. Several states have also made this stipulation either by statute or in the Courts.

 

All disease is one and what medical doctors call diseases are only symptoms of a greater underlying problem. Disease is nothing more than a manifestation of our body trying to correct imbalances. Imbalances due to faulty nutritional patterns, improper rest, stress management and other lifestyle considerations, which over time, result in a weakening of the body. By the time disease appears on the scene it is very late in the game.

 

Our body tells us early on when there is a problem and we can either respond to this message or try to suppress the symptoms that the body uses to tell us there is a problem. You can take ibuprofen or other drugs to suppress the symptoms and they will help for a short time. However, unless the underlying problem is corrected, eventually the symptoms will no longer be helped by these drugs and one will need to take stronger and stronger drugs to quiet the body’s message. If the underlying problem has not been addressed, the body will begin to break down structurally. At this time modern medicine is finally capable of diagnosing that something is really wrong and offer interventions to fix the structure, but still medical doctors fail to address the underlying problem.

 

Naturopathy concentrates on identifying destructive aspects in lifestyles that lead to imbalances. Before symptoms manifest and long before a diagnosis can be rendered, these destructive aspects of our lifestyle can be identified and corrected. Once corrected, the body automatically corrects itself. Diagnosing disease and illness is totally unnecessary to correcting the underlying problems that result in disease and illness. A true healer does not waste his time concentrating on naming diseases but rather on identifying those underlying factors that if not addressed result in the manifestation of disease and illness. These factors can be identified and corrected long before it is even possible to make any diagnosis. Even after a diagnosis is made the same concepts of healing used by classical naturopaths are equally effective because once balance is restored the body automatically heals itself.

 

Since relaxation is key to a better health, it is highly recommended

that you try self-meditation a few times prior to your appointment.

     Download a Free MP3 meditation at http://uThinkWell.com/

HOW TO OBTAIN CURRENT TERMS A CONDITIONS, REFUND POLICIES

 

 

Terms and Conditions. Additional terms and conditions may apply to certain purchases and visits, please visit https://www.biostarorganix.com/tos for the latest information as they may change without notice.

 

Purchases:Each time you make a purchase, the terms and conditions must be checked and accepted upon checkout before releasing the chosen service, products, or other.  The acceptance of terms and conditions deems notification to member of all referred change(s) and/or notification(s). 

 

Services: The services provided by BioStar Organix Healthcare Association are highly speculative in nature, and we do not guarantee that the results of our work will be satisfactory to a member. We reserve the right to refuse service to anyone. Due to time sensitive concerns or other expenses most of our practitioners incurred to offer this service, no refunds are available for appointment visit(s). BioStar Organix Healthcare Association has the right to refuse service and refund the money for the following reasons:

 

  • A practitioner changes/cancels date of appointment.

 

  • A practitioner considers unable to perform services for any reason.

 

 

  • A practitioner considers subject (member) unwilling to cooperate causing creating a conflict of interest.

 

  • If a member show disruptive behavior as to cause or endanger the safety of practitioner, staff, or others.

 

A consultation is fully completed when:

 

  • A session has gone on for thirty (30) minutes.

 

Non-Refundable: All products requiring refrigerated storage or any heat-sensitive items. Any unsealed or opened product.  Box opened or damage.  Missing box or damaged equipment, product or unit.  Any special-orders or special product requested for another member.  

 

Product Return Policy: Undamaged, Sealed/Unopened products returned within 5 days of purchase. After 5 days to a maximum of 30 days, refunds are made in the form of store credit – applied towards future session fees only. No refunds or credit after 30 days.

 

 

 

 

 

 

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Consumer Disclosure Regarding Conducting business electronically,

Receiving Electronic Notices and Disclosures, and Signing Documents Electronically

Please read the following information, by proceeding forward and signing this document you are agreeing that you have reviewed the following consumer disclosure information and consent to transact business using electronic communications, to receive notices and disclosures electronically, and to utilize electronic signatures in lieu of using paper documents. This electronic signature service is provided on behalf of members, “sending party,” whom are sending electronic documents, notices, disclosures or requesting electronic signatures to you.

  • You are not required to receive notices and disclosures or sign documents electronically. If you prefer not to do so, you may request to receive paper copies and withdraw your consent at any time as described below.

Paper CopiesYou are not required to receive notices or disclosures or sign documents electronically and may request paper copies of documents or disclosures if you prefer to do so. You also have the ability to download and print any open or signed documents sent to you through the BioStar Organix electronic signature system using the PDF and Print icons. BioStar Organix may also email you a PDF copy of all agreement you sign using the BioStar Organix service(s). If you wish to receive paper copies in lieu of electronic documents you may request paper copies from the “sending party” by following the procedures outlined below. The “sending party” may apply a charge for requesting paper copies. Use of the Service requires a standards-compliant web-browser, which supports the HTTPS protocol, HTML, and cookies. Viewing PDF documents requiring additional software such as Adobe Reader or similar.

Withdrawal of Consent - You may withdraw your consent to receive electronic documents, notices or disclosures at any time. In order to withdraw consent you must notify the “sending party” that you wish to withdraw consent and to provide your future documents, notices, and disclosures in paper format. After withdrawing consent if at any point in the future you proceed forward and utilize the electronic signature system you are once again consenting to receive notices, disclosure, or documents electronically. You may withdraw consent to receive electronic notices and disclosures and optionally electronically signatures by following the procedures described below.

Scope of Consent - You agree to receive electronic notices, disclosures, and electronic signature documents with all related and identified documents and disclosures provided over the course of your relationship with the “sending party.” You may at any point withdraw you consent by following the procedures described below.

Requesting paper copies, withdrawing consent, and updating contact information

You have the ability to download and print any documents we send to you through the electronic signature system. To request paper copies of documents, withdraw consent to conduct business electronically and receive documents, notices, or disclosures electronically or sign documents electronically please contact the “sending party” by telephone, postal mail, or by sending an email to the “sending party” with the following subjects:

  • “Requesting Paper Copies” Please provide your name, email, telephone number, and postal address and document title.
  • “Withdraw Consent” Please provide your name, email, date, telephone number, postal address.
  • “Update Contact Information” Please pro­­vide your name, email, telephone number and postal address.

Any fees associated with requesting paper copies or withdrawing consent will be determined by the “requesting party.”

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BioStar Organix Healthcare Association

 (A Private Medical Membership Association)

MEMBERSHIP CONTRACT

 

I, _________________________________________, for membership fee paid in hand, do hereby apply for membership in BioStar Organix Healthcare, a private membership organization.  With the signing of this membership agreement I/we accept the offer made to become a member of BioStar Organix Healthcare Association of Los Angeles, California, USA and have read and agree with the following Declaration of Purpose from Article I of BioStar Organix Healthcare Articles of Association.

 

1.     This Association of members hereby declares that our main objective is to maintain and improve the civil rights, constitutional guarantees, and political freedom of every member and citizen of the United States of America.  We believe that the Constitution of the United States is one of the best documents ever devised by man, and the signers of the Declaration of Independence did so out of love for their country.

 

2.         As members, we affirm our belief that the Constitution of the United States is one of the best documents ever devised by man and the signer of the Declaration of Independence did so out of love for their country. We believe that the First Amendment of the Constitution of the United States of America guarantees our members the rights of free speech, petition, assembly, and the right to gather together for the lawful purpose of advising and helping one another in asserting our rights under the Federal and State Constitutions and Statutes. We strive to maintain and improve the civil rights, constitutional guarantees, freedom of choice in health care and political freedom of every member and citizen of the United States of America. 

 

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.  This means that our association activities are restricted to the private domain only.

 

3.     We declare the basic right of all of our members to select spokesmen from our number who could be expected to give wisest counsel and advice concerning the need for physical and mental health care assistance and to select from our number those members who are the most skilled to assist and facilitate the actual performance and delivery of therapy, treatment and care.

 

4.     We proclaim the freedom to choose and perform for ourselves the types of therapies and treatment modalities that we think best for diagnosing, treating and preventing illness and disease of our minds and bodies and for achieving and maintaining optimum wellness.  We proclaim and reserve the right to include medical and 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. 

 

 

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5.     More specifically, the mission of our Association is to provide members with the highest level of quality care and the most effective methods of treatment.  We treat members and their health and medical condition, and not merely the symptoms experienced.  Our Association understands that wellness has many dimensions and strives every day to stay on the leading edge of new technology.  The Association provides comprehensive, conventional, complementary alternative care and the most advanced technologies to diagnose all aspects of a member’s disease and provide the most effective means of treatment at an affordable fee.  More specifically, the Association specializes in, but not limited to, Hypnosis and Meditation, Bio- resonance Analysis of Health (or B.A.H. for short) is a multi-faceted and comprehensive diagnostic method. It can be used to evaluate all aspects of an individual’s health, identify all dysfunctions, and create a unique program of treatment that best suits the individual patient. Bio-resonance Analysis of Health will allow our practitioners to precisely determine what vitamins, supplements, remedies, and procedures are the most effective in the treatment of the individual person. This system also allows for great detail - from dosage, to duration, and even the time of day that would most benefit the patient. Additionally, the Association specializes in diets, hypnosis treatments for cancer, addiction, emotional stress, spiritual counseling, marriage, addiction, behavioral modification and regression, education.  The Association utilizes electronic biofeedback, digital meridian testing, ionic and micro-frequency stimulation (for parasites and microbiological organisms, heavy metal detoxification), live/dry blood analysis, audio and video recording, photography of the face, eyes, ears, hands and live and dry blood, magnets, moxa, various essential oils for pain and emotional balance, massage, reflexology, and light touch, hyperbaric oxygen chambers, far infrared sauna, heat pads and foot baths for detoxification as alternates to medication concerning the modalities of service and benefits to members.

 

6.     The Association will recognize any person (irrespective of race, color, or religion) who is 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 the fellow members of the Association that provides services and care, do so in the capacity of a fellow member and not in the capacity as a licensed health care provider.  I further understand that within the association no doctor-patient relationship exists but only a contract member-member Association relationship.  In addition, I have freely chosen to change my legal status as a public patient, customer or member to a private member of the Association. I further understand that it is entirely my own responsibility to consider the advice and recommendations offered to me by my fellow members and to educate myself as to the efficacy, risks, and desirability of same and the acceptance of the offered or recommended diagnosis, therapy, treatment and care is my own carefully considered decision.  Any request by me to a fellow member to assist me or provide me with the aforementioned diagnosis, therapy, treatment and care is my own free decision in an exercise of my rights and made by me for my benefit, and I agree to hold the Trustee(s), staff and other worker members and the Association harmless from any unintentional liability for the results of such care, except for harm that results from instances of a clear and present danger of substantive evil as determined by the Association, as stated and defined by the United States Supreme Court.

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The Trustees and members have chosen Ulysses L. Angulo as the person best qualified to perform services to members of the Association and entrust him to select other members to assist him in carrying out that service.

 

In addition, 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 Committee and will be waived by the member for the benefit of the Association and its members. Because the privacy and security of membership records maintained within the Association which have been held to be inviolate by the U.S. Supreme Court, the undersigned member waives HIPAA privacy rights and complaint process.  Any medical or healthcare records kept by the association will be strictly protected and only released upon written request of the member.  I agree that violation of any waivers in this membership contract will result in a no contest legal proceeding against me.  In addition, 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.

 

I agree to join the Association, a private membership association under common law, whose members seek to help each other achieve better health and live longer with good quality of life.

 

I understand that the doctors, nurses, and other providers who are fellow members of the Association are offering me advice, services, and benefits that do not necessarily conform to conventional medical care.  I do not expect these benefits to include on-call coverage, hospital care, or the usual and customary care provided by most physicians.  I will receive such primary and specialist care elsewhere.  I fully understand that the benefits I receive from the Association might or might not be covered by my health insurance and not at all by Medicare.

 

As a member, I accept the goals of helping my body function better and choosing techniques that are both very safe and have a reasonably good chance to succeed, realizing that no diagnostic technique or treatment is foolproof.  If I choose to forgo drugs, surgery, or radiation that has been recommended to me by others, I fully accept the risk that I might suffer serious consequences from that choice.  Other aspects of informed consent will take place in my discussions with the providers and my fellow members of the Association.

 

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 file a malpractice lawsuit against a fellow member of the Association, unless that member has exposed me to a clear and present danger of substantive evil.  I acknowledge that the members of the Association do not carry malpractice insurance.

 

 

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Patient Disclosure for California Senate Bill SB-577 Compliance

 

I, Ulysses Angulo, am a Certified Natural Health Practitioner (CNHP), Consulting Hypnotist and Healing Arts Practitioner. I am not a physician; I am not licensed by the state as a healing arts practitioner and may not provide a medical diagnosis nor recommend discontinuance of medically prescribed treatments. In order to use my services, California state law requires that you acknowledge receipt of the information provided in this form and that you sign it, keep a copy for yourself, and that I keep the one you give me for at least three years.

 

My method of service: In “holistic art nutrition and classic naturopathy” an alternative or complementary to healing arts that are licensed by the State of California. Under Sections 2053.5 and 2053.6 of California’s Business and Professions Code, I can offer you these services, subject to requirements and restrictions that are described fully on your membership contract. The idea behind “holistic arts nutrition and classic naturopathy” is as follows:

  • Holistic Arts Nutrition is the practice of correcting imbalances that cause disease and boosting the digestive and immune system by providing the body with optimal amounts of substances that are natural to the body.
  • Classic Naturopathy is an "alternative“ or "complementary" educational approach to health and wellness which focuses on achieving the appropriate balance required for optimal health in the areas of: lifestyle (diet & nutrition, physical fitness, etc.), mental well-being (stress reduction, healthy relationships, etc.), and spirituality (religious beliefs, personal philosophies, character development).  (See pg. 2  for more details.)

 

Redress: If a member desires a diagnosis or any other type of treatment from a licensed professional, the member may seek such services at any time. In the event a member terminates their services, the member has a right to coordinated transfer of services to another practitioner. A member has a right to refuse healthcare or hypnosis services at any time. A member has a right to be free of physical, verbal or sexual abuse. A member has a right to know the expected duration of treatment, and may assert any right without retaliation. In the event you are not satisfied with my services I request that you speak to me promptly and personally about your concerns.

 

My Approach: The member is educated to view the self as one or a "whole being," hence the name. As a practitioner of holistic clinical nutrition, and holistic patient education, I will provide you with personal consultations that are educational in nature. They will be based on your personal needs and unique profile. I may inform you about the proper scheduling of certain dietary vitamins, minerals, herbs, or other supplements, and teach you about how certain changes to your lifestyle or outlook may improve your health and wellness. I may show you certain self-assessment techniques such as use of blood tests, pressure cuff or to palpate (feel) yourself for tenderness in various points. I may also demonstrate blood testing, muscle strength testing, use of self-hypnosis, and use of biofeedback also known as “energy testing” systems (e.g. DIACOM, ZYTO or ACUGRAPH).

 

Contact Information: phone (323) 698-8777, fax (323)665-2498, email: orders@biostarorganix.com

 

 

 

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Special Assessments / Fees: The standard charge for my services is $120 per session. 24-hours advance cancellation notice is kindly requested. I accept most credit cards. I will provide you with the documentation you need to bill your insurance company if they cover the cost of my services, although most unlikely. See Special Assessments on page 1.

 

Audio/Video Recording: All Hypnosis services are recorded, at no charge to the member. Any audio recording of a hypnosis session is a gratuity and is not part of the hypnosis fee. We do not guarantee that the tape will be audible, fully intact or usable. We will not be responsible for nor issue refunds for defective or damaged tapes.

 

Warranty: No Warranty is given, expressed or implied for specific results from Spiritual Counseling / Health consultations or Hypnosis session(s).

 

Confidentiality: I will not release any information to anyone without a written authorization from you, except as provided for by law. You have a right to be allowed access to my written record about you.

 

Number of Consultation Sessions: The number of sessions generally will vary from a minimum of two to several visits depending upon the behavior modification desired. Sessions are designed with the member to meet individual needs. Please be informed that I do not treat emotional, medical or psychological disorders but use verbal directions while you are relaxed to guide you in meeting your stated goals.

 

If you ever have any concerns about the nature of my education, please feel free to discuss them with me.

My training and education is described below:

  • I have been certified as a Natural Health Specialist (CNHP) from the Trinity School of Natural Health – http://trinityschool.org/
  • I have been certified as a Fellow at the Institute of Human Individuality http://www.generativemedicine.org/ifhi/
  • I have received training in Live/Dry Microscopy, Finger Nail and Tongue Analyst, Aromatherapy. http://www.cnhp.org/  http://www.chi-health.com
  • I am trained in hypnotherapy and with certification from the Sylvia Browne Hypnosis Training Center. As the state of California has not adopted educational and training standards for the practice of hypnotherapy, this statement of credentials is for informational purposes only.  http://www.sylviabrownehypnosis.org/
  • I have been ordained as a Minster from Universal Life Church and confer members with spirituality (e.g. Gnostic Christianity from Novus Spiritus http://novus.org.)

 

Hypnosis Methods Used: The Hypnotist employs Spiritual Counseling and hypnosis techniques to facilitate the member’s quest for self- improvement. Specific techniques may include but is not limited to: Spiritual Philosophy, Body Relaxation, Directed Meditation, Age Regression, Cell Memory, Past-Life Regression, and/ or Behavior Modification.

 

 

 

 

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When signing this membership agreement you acknowledge and understand that California has specific laws pertaining to the use of hypnosis to enhance or recover memories to aid in testifying in criminal matters and that those laws may also impact civil cases if the hypnosis is used for the same purposes. Use of hypnosis to aid memory or recall for court testimony may result in the inadmissibility of that testimony. I advise you to contact your attorney if and questions exists in your mind as to whether you may effect legal rights in matters currently pending by the use of hypnosis.

 

Forensic Hypnosis: By signing below you are agreeing that you are not currently involved in any criminal or civil matters where you are seeking to enhance or develop memories for use in litigation. Member agrees to hold the hypnotherapist harmless, to defend and indemnify the hypnotherapist from any claims, including all attorneys' fees and costs related to the so-called creation of memories or testimony that may arise or be related.

 

State law requires that I recommend that you inform your medical doctor that you are receiving “holistic arts services and classic naturopathic education”. Please remember that doctor, nutritionists, herbalists, and other medical professionals and health practitioners hold widely varying views. I intend to offer health information to help you cooperate with a competent medical doctor (MD) in your mutual quest for health. In the event you use this information without your medical doctor’s (MD’s) approval, you prescribe for yourself – then Ulysses Angulo and members of BioStar Organix Healthcare Association assumes no responsibility.

 

 

Patient Disclosure for California Senate Bill SB-577 Compliance

 

Acknowledgement and Consent to Receive Services Statement:

 

I agree and understand, the above disclosure about the holistic arts and clinical nutrition, and the holistic arts services and classic naturopathic education offered by Ulysses Angulo including his training and education. I have discussed with Ulysses Angulo the nature of the services to be provided. I understand that Ulysses Angulo is not licensed by the state as a healing arts practitioner, or hypnotist or any other service of the Association. I understand it is my responsibility to maintain a relationship for myself/my child with a medical doctor. I have consented to use the services offered by Ulysses Angulo or members of BioStar Organix Healthcare Association, and agree to be personally responsible for the fees of BioStar Organix Healthcare Association in connection with the services provided to me. I understand I may not receive any insurance reimbursement or a tax deduction for these services.

 

 

 

 

 

 

 

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(For more information visit: http://www.californiahealthfreedom.com)

The foregoing is true and correct to the best of my knowledge and I agree to be bound by my own representation.

 

I enter into this agreement of my own free will or on behalf of my dependent without any pressure or promise of cure.  I affirm that I do not represent any State or Federal agency whose purpose is to regulate and approve products.  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.  These pages and Article I of the articles of association of the Association consist of the entire agreement for my membership in the Association and they supersede any previous agreement.

 

I understand that the membership fee entitles me to receive those benefits declared by the Trustee(s) to be “general benefits” free of further charge.  I agree to pay as levied those benefits that I receive that are declared by the Trustees to be “special assessments”, per Fee Schedule. I fully understand and I agree with it and to do business electronically with BioStar Organix Healthcare and agree that I have reviewed the consumer disclosures related to electronic signatures.

 

I enclose the sum of $_____.00 as consideration for my lifetime membership contract, said term beginning with the date of the signing of this contract, and by these presents do hereby certify, attest and warrant that I have carefully read the above and foregoing BioStar Organix Healthcare’s Contractual Application for Membership, and I fully understand and agree with same.

 

IN WITNESS WHEREOF,

 

(Print) Name:

 

 

_________________________ / _______________________

 

Member                                      Parent or Legal Guardian

 

I have read and received an electronic copy of this agreement.

 

 Member

Signature: X                                                                                      Date: 

 

Indicate capacity to sign if other than (Self):   ____Parent   ____Guardian

 

BioStar Organix Healthcare Association:     

Membership via: __Online  __In-person

Invoice#:

Approved By:____________________________

Payment: $

  Date:                                20____ 

 

Confidential Member Information Form

 

 

First Name: ___________________ Last Name:________________________

 

Address: _______________________________________________________

 

City: _________________________ State:_______     Zip Code:___________

 

Cell Phone: (_____) ____________--__________________

 

Email: ______________________ @ __________________

 

Occupation: _____________________ DOB: _________ Birth Time: _______

 

Blood Type:                                            Referred by:

 

Are you currently under the care of a doctor or psychologist?

 

NO____ YES_____

lf yes, please explain________________________________________________

 

Do you have any past medical conditions or psychological history that the practitioner should be aware of before the session?

 

NO____ YES_____

lf yes, please explain________________________________________________

 

Did you notify your qualified medical physician that you are working with a Holistic Arts Practitioner?  YES____ NO_____ N/A _____

 

Optional - Have you ever been hypnotized and/or regressed?

NO ___ YES______  

lf yes, please explain________________________________________________

 

________________________________________________________________

 

What do you want to accomplish or let your practitioner know?