HIPAA Release Form
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.
Form of Disclosure:
Section III – Reason for Disclosure
This info is being shared to receive organizational incentives, determined by LifePoint Health,
for participating in a wellness program.
Section IV – Who Can Receive My Health Information
I give authorization for the health information detailed in section II of this document to be shared with
the following individual(s) or organization(s):
1086 Franklin Street
15905 United States
I understand that the person(s)/organization(s) listed above will not use or disclose the information
listed under Section II unless it is required by state or federal law.
Section V – Duration of Authorization
This authorization to share my health information is valid: For two years 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:
Wellness U 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 incentives offered by the party mentioned