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.