Authorization

Authorization to Obtain or Release Information – Health Management Activities

I understand that by agreeing to participate in the It’s Your Life Services, LLC (“It’s Your Life”) or the health management program of Henry Ford Jackson Hospital, I will be required to complete a Health Risk Appraisal. I consent to the sharing of data from my Electronic Health Record on biometrics including height, weight, blood pressure, cholesterol, glucose and/or A1c in order to supplement the data I provide in the Health Risk Appraisal. If data is not available from my physician or my Electronic Health Record, 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 (all of this, including Personal Health Information, “Personal Information”).

I consent to and authorize my Personal Information to be given to Henry Ford Jackson Hospital and/or and any of its designees, including Jackson Health Network, LC3 (“JHN”), the service provider of care management services (if applicable), and Health Alliance Plan (“HAP”), the Health Risk Appraisal vendor, and its vendors, 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 Henry Ford Jackson Hospital health management program and wellness coaches and to my Primary Care Physician (“PCP”) in order to coordinate followup education and health care treatment.

I authorize health employees or agents of the It’s Your Life and/or Henry Ford Jackson Hospital 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 or, only in the case of my participation in the Care Management program, care management staff to access and document relevant health information in order to coordinate my care.

I understand that this authorization is not for marketing purposes and It’s Your Life and/or Henry Ford Jackson Hospital 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.

This authorization is effective for the entire time that I participate in the It’s Your Life or Henry Ford Jackson Hospital health management program and will expire when I no longer participate in the health management program. I understand that I may revoke this authorization at any time by notifying It’s Your Life and/or Henry Ford Jackson Hospital in writing, at the address below. The revocation, however, will not be valid to the extent It’s Your Life and/or Henry Ford Jackson Hospital has taken action in reliance on this authorization.

I acknowledge that a copy of the Privacy Notice has been made available to me. I understand that a copy of this signed authorization will be provided to me, upon request.