Coaching Consent Agreement
Authorization to Disclose Protected Health Information to Coaching Company
This Authorization is separate from, and in addition to, the general consents you have signed to receive care from Protocol Health Club. Protocol Health Club cannot condition your treatment on whether you sign this Authorization, except where your bloodwork or program has been arranged and paid for by a coaching company as described below.
This Authorization applies ONLY to patients whose bloodwork was paid for by a coaching company as part of that company's coaching offer. If your bloodwork was not paid for by a coaching company, this Authorization does not apply to you and Protocol Health Club will not share your information with any coaching company.
1. Purpose of This Authorization:
If your bloodwork was arranged for and paid for by a third-party coaching company as part of its coaching offer, that company may need certain of your health information to coordinate your coaching program with the care you receive from Protocol Health Club. This Authorization allows Protocol Health Club to share that information, and only that information described below, with that coaching company.
2. Coaching Company Receiving the Information
Protocol Health Club will share the information described below with the coaching company that arranged for and paid for the patient's bloodwork as part of its coaching offer.
3. Information to Be Disclosed
Protocol Health Club is authorized to disclose only the following information to the coaching company that arranged and paid for the patient's bloodwork:
1. Information regarding the patient's bloodwork.
2. Information regarding the agreed-upon supplements, peptides, and therapies that the patient will be undergoing.
3. Information seen as relevant for the coach to best support the client on their fitness journey.
No other information will be shared. This Authorization does NOT extend to psychotherapy notes or to any information beyond what is specifically identified above, unless separately authorized in writing.
4. Purpose of the Disclosure
To allow the coaching company to coordinate and support the coaching services it provides to you in connection with the bloodwork or program it has arranged or paid for.
5. Expiration
This Authorization will remain in effect for the duration of your active coaching program with the coaching company that arranged and paid for the patient's bloodwork, or for one (1) year from the effective date of this Authorization, whichever occurs first, unless revoked sooner in writing.
6. Your Right to Revoke
You may revoke this Authorization at any time by submitting a written request to Protocol Health Club's Privacy Officer. Your revocation will be effective upon receipt, except to the extent Protocol Health Club has already relied on this Authorization to make a disclosure before receiving your revocation.
7. Redisclosure Notice
Once your health information is disclosed to the coaching company under this Authorization, federal privacy law (HIPAA) may no longer protect it, and the coaching company may not be required by HIPAA to safeguard it in the same manner as Protocol Health Club. Protocol Health Club is not responsible for the coaching company's further use or disclosure of your information once it has been shared.
8. Voluntary Authorization
Your decision to sign this Authorization is voluntary. Protocol Health Club will not condition your treatment, payment, enrollment, or eligibility for benefits on whether you sign this Authorization, except to the extent your bloodwork or program was specifically arranged for and paid for by the coaching company that arranged and paid for the bloodwork, and sharing this information is necessary for the coaching company to continue that arrangement.
By agreeing to this Authorization, I acknowledge that I have read and understand it, that I have had the opportunity to ask questions, and that I voluntarily authorize Protocol Health Club to disclose the information described above to the coaching company that arranged and paid for my bloodwork.
A copy of this Authorization will be provided to you upon request. If you have questions about this Authorization, please contact Protocol Health Club's Privacy Officer.
I understand that by submitting an application to book a sales call, I am providing written instructions authorizing PROTOCOL HEALTH CLUB, LLC and its affiliates to obtain my personal credit profile or other information from credit reporting agencies under the Fair Credit Reporting Act (FCRA) solely to conduct a credit pre-qualification. I further understand that this is a soft inquiry and will not impact my credit score in any way whatsoever.
