Authorization to Obtain or Release Information – Health Improvement Activities
I understand that by agreeing to participate in It’s Your Life Services, LLC (“It’s Your Life”) and/or Henry Ford Allegiance Health (“HFAH”) health management program, I will be required to complete a Health Risk Appraisal and I consent to share data from my Electronic Health Record on biometrics including height, weight, blood pressure, cholesterol and glucose. If data is not available from my physician, I consent to allow blood samples to be taken from me and the laboratory analysis of said blood samples for the purpose of determining cholesterol and glucose A1c (all of this, including Personal Health Information, “Personal Information”).
I consent to and authorize the use of my Personal Information to be given to It’s Your Life and/or HFAH and any of its designees, for the purposes listed herein. In addition, I consent to and authorize It’s Your Life and/or HFAH and any of its designees, including Health Alliance Plan (“HAP”) or other Health Risk Appraisal vendor, to make and deliver the following information:
(1) my personal health profile report to me,
(2) an aggregate report to my employer (with Personal Information de-identified), and
(3) my Personal Information to authorized health employees or agents of the It’s Your Life and/or HFAH health management program and wellness coaches and to my Primary Care Physician (“PCP”) in order to coordinate follow- up education and health care treatment.
(4) I authorize health employees or agents of the It’s Your Life and/or HFAH health management program and wellness coaches to access and document relevant health information in my Electronic Health Record, limited to Personal Information related to health management and preventive services.
I understand that this authorization is not for marketing purposes and It’s Your Life and/or HFAH will not receive remuneration from a third party for use of this protected health information. I understand that this authorization is voluntary and that I may refuse to sign this authorization. In the event that I refuse to sign this authorization, I understand that I will not be able to participate in the It’s Your Life Health Management Program.
I understand that I may revoke this authorization at any time by notifying It’s Your Life and/or HFAH in writing, at the address below. The revocation, however, will not be valid to the extent It’s Your Life and/or HFAH has taken action in reliance on this authorization. This authorization expires three (3) years after I stop participating in my employer’s health care benefit program.
I acknowledge that: A copy of the Privacy Notice was made available to me. I understand that a copy of this signed authorization will be provided to me, upon request.
Check the box below and submit the form to enroll in the program and to confirm that you understand the program requirements described above.
Checking this box is your electronic signature that you agree to enroll in the program and confirms that you understand the program requirements as described above.
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