Please complete all sections of this HIPAA release form. If any sections are left blank, this form will be invalid and it will not be possible for your health information to be shared as requested.

Section I

I give my permission for Wellness U LLC dba Hope 80/20,  to share the information listed in Section II of this document with the person(s) or organization(s) I have specified in Section IV of this document.

Section II – Health Information

I give the above healthcare organization permission to: 

Disclose my online course attendance quarterly.

Form of Disclosure:

Electronic copy

Section III – Reason for Disclosure

This info is being shared to receive organizational incentives, determined by Conemaugh Health Systems, for participating in a wellness program.

Section IV – Who Can Receive My Health Information

By clicking “accept” and typing your name on our HIPAA Release Form you are agreeing to this Conemaugh HIPAA Release Form and your info will be released accordingly.

Section V – Duration of Authorization

This authorization to share my health information is valid: 

For one year (365 days) from signature date.

I understand that I am permitted to revoke this authorization to share my health data at any time and can do so by submitting a request in writing to:

WellnessU LLC dba Hope 80/20

2906 N Ocoee St. 

Cleveland, TN 37311

I understand that:

• In the event that my information has already been shared by the time my authorization is revoked, it may be too late to cancel permission to share my health data.
• I understand that I do not need to give any further permission for the information detailed in Section II to be shared with the person(s) or organization(s) listed in section IV.
• I understand that the failure to sign/submit this authorization or the cancellation of this authorization will prevent me from receiving any quarterly incentives offered by Conemaugh for participation in a wellness program.

Section VI – Signature

Signature: __________________________________ 

Date: __________________________

Print your name: _____________________________________________________________

If this form is being completed by a person with legal authority to act an individual’s behalf, such as a parent or legal guardian of a minor or health care agent, please complete the following information:

Name of person completing this form: ______________________________________

Signature of person completing this form: ______________________________________

Describe below how this person has legal authority to sign this form: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________