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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

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”), 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 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:

my personal health profile report to me, 
an aggregate report to my employer (with Personal Information de-identified), and  
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.

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 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

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”), 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 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), 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.

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. 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.

Spouse Information

By checking this box, I consent to and authorize the release of information about my participation in It’s Your Life and/or HFHA health management program to my spouse, including details about my program status and preventive screen compliance. We require your spouse’s name and ID number to ensure that we are releasing the information to the appropriate person.