I authorize Prime, Inc. to use and disclose the protected health information described below for participation in the Prime Driver Health and Fitness' Fit in 15 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 and BMI information only.
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 Fit in 15 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.
P.O. Box 4208
Springfield, MO 65808