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*Indicates a required field By clicking this box, I am acknowledging that I have voluntarily elected to partake in the services provided by Neighborhood Care, owned and operated by EmblemHealth Services Company, LLC (“EmblemHealth”). I hereby confirm and acknowledge that any and all information relayed to me during this class is purely for informational and educational purposes. I understand that I should seek prior consultation and approval from a licensed physician or an applicable health care provider before acting on or implementing any information received. Additionally, I understand and forever release EmblemHealth, its affiliates and employees from and against any and all demands or claims whatsoever, that I or my heirs have, or hereafter may have against the EmblemHealth, arising out of my attendance or participation in any of the educational/informative sessions or activities offered at Neighborhood Care. Furthermore, I take full responsibility for the verification and validation by a licensed health care provider or applicable healthcare service provider regarding any information that I may receive. I understand that this information is for general educational purposes only and is in no way a tailored or personalized treatment plan or consultation. This waiver and release of claims is without limitation, and includes a waiver against negligence of any agent, employee, licensee or invitees of EmblemHealth.*

By clicking this box I am attesting that I have read this Acknowledgement Waiver and General Release, and that I understand and agree to be legally bound by its terms.*

I agree to receive e-mail communications regarding information about the class or event I am registering for. *

I understand that the phone number I provided on this form may be used by EmblemHealth or any of its contracted parties to contact me about my account, my health benefit plan or related programs, or services provided to me. *

I would like to receive updates and information about classes and events from EmblemHealth.

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Any information provided on this Website is for informational purposes only. It is not medical advice and should not be substituted for regular consultation with your health care provider. If you have any concerns about your health, please contact your health care provider's office.

Also, this information is not intended to imply that services or treatments described in the information are covered benefits under your plan. Please refer to your Membership Agreement, Certificate of Coverage, Benefit Summary, or other plan documents for specific information about your benefits coverage.

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