LifePoint Health

HIPAA Release Form

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.

Form of Disclosure:
Electronic copy



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):

LifePoint Health
1086 Franklin Street
Johnstown, PA
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