Diabetes Prevention and Management Program HIPAA Privacy and Authorization Form

**Authorization for Use or Disclosure of Protected Health Information. (Required by the Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164) ** This form must be signed to participate in this program so that we can gather height, weight, A1C, blood glucose, and lipid panel (HDL, LDL, Triglyceride, Total Cholesterol), and other identifiable protected health information such as name, phone number, driver code, and email.

I authorize Prime, Inc. to use and disclose the protected health information described below for participation in the Prime Driver Health and Fitness' Diabetes Management Program.
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 authorize the release of my height, weight, name, driver code, phone number, email, A1C, blood glucose, and lipid panel (HDL, LDL, Triglyceride, Total Cholesterol)

This information may be used for consultation, coaching, reporting and promotion, or other purposes. 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 understand that my eligibility for participation in the Diabetes Management Program will be conditioned on whether I sign this authorization. I understand that information may be disclosed by the recipient and may no longer be protected by federal or state law.

Prime Inc.

P.O. Box 4208 Springfield, MO 65808 Nationwide/ 800-321-4552 Fax/ 417-521-3994