I authorize Prime Driver Health and Fitness to use the protected health information described below for health and lifestyle coaching.
This authorization for release of information covers the period from the start of my association at Prime until my termination of association with Prime.
I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization.
I authorize the release of my name, driver code, phone number, email and lab result information.
Understand that federal and state law, including the Health Insurance Portability and Accountability Act (“HIPAA”), protects the privacy and confidentiality of “protected health information” (“PHI”). PHI is defined as any information that identifies an individual and that relates to the past, present or future physical or mental health or condition of an individual or the provision of health care to an individual.
Prime's Driver Health and Fitness staff have the obligation to treat all information about Prime employees in a strictly confidential manner. Discussing or electronically sharing confidential information to any person outside of the DHF department does not and will not occur.
This information obtained from the lab results may be used for consultation and coaching with the DHF staff. This information may be used for future development of DHF programs but without names, driver odes, phones or email information attached.
I (DHF staff member) agree to keep all confidential information, including PHI specific to Prime associates in strict confidence.