Healthcare Wellness Council Form

Healthcare Wellness Council Form

The Healthcare Wellness Council provides coordinated wellness services, health education, and peer support. Participation is voluntary. Completion of this form documents participant information, relevant medical history, goals, and authorization to share limited health information with council staff and members for the purposes of program participation, care coordination, and follow-up.

Participant Information

Participant Name:

Date of Birth:    Gender:

Emergency Contact

Name:    Relationship:

Insurance Information

Policy Number:    Group Number:

Medical History & Current Health

Wellness Goals & Program Preferences

Nutrition & Healthy Eating    Physical Activity & Exercise    Stress Management

Chronic Disease Self-Management    Smoking Cessation    Other:

Consent to Participate and Authorization to Share Information

I authorize the Healthcare Wellness Council and its designated staff and volunteers to collect and share limited protected health information (PHI) about me among council members and partnering clinical staff for the purpose of participation, care coordination, program delivery, referrals, and follow-up. Information that may be shared includes relevant medical history, medication lists, allergies, screening results, and participation notes. I understand that this authorization does not permit release of psychotherapy notes or unrelated mental health records unless specifically listed below.

This authorization expires on: . If no date is provided, this authorization will remain in effect for one year from the date of signature below unless revoked earlier in writing.

I understand that I may revoke this authorization at any time by submitting a written revocation to the Wellness Council coordinator. Revocation will not affect disclosures made prior to receipt of revocation. I understand that treatment, program participation, or insurance eligibility will not be conditioned on signing this authorization except where allowed by law.

Additional specific disclosures authorized (if any):

HIPAA Acknowledgment & Confidentiality

The Wellness Council will treat your health information in accordance with applicable privacy laws. By checking the box below, you acknowledge receipt of the council's privacy practices and agree that limited PHI may be used and disclosed as described in this form for care coordination and program activities.

I acknowledge receipt of the Wellness Council privacy practices and consent to the limited use and disclosure described above.

Risks, Benefits, and Participant Rights

Participation may provide benefits such as improved health knowledge, coordinated services, and peer support. Risks may include inadvertent disclosure of limited information, emotional discomfort during program activities, or recommendations that you choose not to follow. You have the right to decline any activity, ask questions, and withdraw from participation at any time without penalty to your healthcare access.

Certification

By signing below I certify that the information I have provided is true and accurate to the best of my knowledge. I understand the scope of this authorization and my rights concerning revocation and access to information. I authorize participation in Wellness Council activities and the limited exchange of information as described above.

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