Authorization

Authorization to Obtain or Release Information – Health Management Activities

• I will be required to complete a health risk appraisal.
  • I agree to the sharing of data from my electronic health record on biometrics including height, weight, blood pressure, cholesterol, glucose, or A1c to supplement the data I provide in the health risk appraisal.
  • If data is not available from my doctor or my electronic health record, I consent to allow blood samples to be taken from me and the laboratory analysis of the blood samples for the purpose of determining cholesterol and glucose.
• My personal information to be given to Mosaic Clinically Integrated Network, LLC (CIN) or any of its designees, including Henry Ford Health (HFH) and Populance, the service provider of care management services (if applicable), and Health Alliance Plan (HAP), the Health Risk Appraisal vendor, and CIN’s vendors to make and deliver the following information:
  • My personal health profile report to me
  • An aggregate report to my employer (with personal information de-identified)
  • My personal information to authorized health employees or agents of HFH or CIN health management program and wellness coaches and to my primary care physician to coordinate follow-up education and health care treatment.
• Health employees or agents of HFH or CIN health management program and wellness coaches to access and document relevant health information in my electronic health record. It will be limited to personal information related to health management and preventive services.
  • In the case of participation in the Care Management program, care management staff will access and document relevant health information to coordinate my care.
• This is not for marketing purposes and HFH and CIN will not receive remuneration from a third party for use of this protected health information.
• This is voluntary. I may refuse to sign this authorization. If I refuse to sign, I know I will not be able to participate in the health management program.
• This is effective the entire time I participate in the health management program. It will expire when I no longer participate in the health management program.
• I can revoke this authorization at any time by notifying CIN in writing. I can send this to ‘One Jackson Square 5th Floor, Jackson, MI 49201’ or fax to (517) 205-5941. I understand the revocation will not be valid to the extent CIN has already taken action based on this authorization.

This form was explained to me. I was able to ask questions. A copy of the privacy notice has been made available to me. I understand a copy of this form will be provided to me upon request.