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It's Your Life Enrollment Form

Personal Information
Legal first name, i.e. James not Jim.
Authorization to Obtain or Release Information

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”), 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, accreditation, billing, and evaluation of an application or claim.

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 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 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 or other Health Risk Apraisal vendor, 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 and wellness coaches and to my Primary Care Physician (“PCP”) in order to coordinate follow-up education and health care treatment, and 

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 six (6) years after I stop participating in my employer’s health care benefit program.

I acknowledge that: A copy of the Privacy Notice is available to me. I understand that a copy of this signed authorization will be provided to me, upon request.

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 Allegiance Health (“Allegiance Health”), and any of their designees, such as the University of Michigan’s Health Management Research Center (“HMRC”) 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, accreditation, billing, 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 Allegiance Health staff members.

I also authorize my employer(s), and any of its (their) designees, to give to It’s Your Life and/or Allegiance Health and any of their designees, including HMRC 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 Allegiance Health 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 Allegiance Health and any of its designees, including HMRC and/or JHN, for these purposes listed herein, and I consent to and authorize that It’s Your Life and/or Allegiance Health and any of its designees, including HMRC 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 Allegiance Health health management program, JHN care coordinators, 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 Allegiance Health 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 if the person or entity that receives the information is not a health care provider or health plan covered by state or federal laws and regulations, the information described above may be re-disclosed and no longer protected by applicable laws and regulations.

I understand that I may revoke this authorization at any time by notifying It’s Your Life and/or Allegiance Health in writing, at the address below.  The revocation, however, will not be valid to the extent It’s Your Life and/or Allegiance Health has taken action in reliance on this authorization.  This authorization expires 6 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. The Privacy Notice is posted in a clear and prominent location where I am able to read the Privacy Notice. I know that I can ask for a copy of the Privacy Notice to take with me. I understand that a copy of this signed authorization will be provided to me.

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.