Please read the waiver below and complete the questions at the bottom.  You may not participate in health coaching or care management without completing the waiver.  

Question Title

* 1. Authorization to Obtain or Release Information – Health Improvement Activities 
On behalf of myself (“me”), I authorize any healthcare professional or entity to give to It's Your Life Services, LLC (“It’s Your Life”), and/or W.A. Foote Memorial Hospital d/b/a Henry Ford Allegiance Health (“HFAH”), and any of their designees, such as Health Alliance Plan (“HAP”) and/or Jackson Health Network, L3C (“JHN”), any and all records or information (past, present, and future) pertaining to medical history, claims payment history, or services rendered to me (“Personal Health Information”) for administrative or other purposes, including, but not limited to, treatment, coordination of care, quality assessment and measurement, and evaluation of an application or claim.  I understand that this authorization includes authorization to release information about alcohol and drug abuse protected by Federal Regulations 42 CFR Part 2, if any, Behavioral Health records, HIV/AIDS related records, if any, and social services records, if any, including communications made by me to my psychiatrist, therapist, physician, social worker, or other HFAH staff members.

I also authorize my employer(s), and any of its (their) designees, to give to It’s Your Life and/or HFAH and any of their designees, including HAP and/or JHN, any and all records or information (past, present, and future) pertaining to me including, but not limited to, Personal Health Information, absentee data, workers compensation claims data, disability insurance claims and health insurance claims data for care coordination and analytical research purposes, including producing the reports listed below. I understand that designees of my employer includes my employer’s health insurer, its Third Party Administrator, other health plan service providers, and  care management service providers.

I also authorize on behalf of myself, the use of a unique identification number for purposes of identification. 

I understand that by agreeing to participate in It’s Your Life and/or HFAH health management program, I will be required to complete a Health Risk Appraisal and 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, glucose, and Hemoglobin 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, including HAP and/or JHN, for these purposes listed herein, and I consent to and authorize that It’s Your Life and/or HFAH and any of its designees, including HAP and/or JHN, may 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), 
(3)     my Personal Information to authorized health employees or agents of the It’s Your Life and/or HFAH health management program, JHN care coordination, and wellness coaches and to my Primary Care Physician (“PCP”) in order to coordinate follow-up education and health care treatment, and 
(4)      my Personal Information to my employer(s)’ authorized designee acting as its health insurance third party administrator  (“TPA”), for modeling and analytical purposes and to my employer’s care management service providers for care coordination.

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.

Sign below to enroll in the program and to confirm that you understand the program requirements as described above.

Question Title

* 2. First Name

Question Title

* 3. Last Name

Question Title

* 4. Date of Birth

Date

Question Title

* 5. Email address

T