BEATDiabetes Sign-up Form - Type 2 Diabetes

01 Eligibility
02 Enrollment Form
03 Release of Information

Authorization for Use/Disclosure of Information:  I voluntarily consent to authorize my health care provider, to disclose my health information during the term of this Authorization to the recipient that I have identified below.

Recipient:  I authorize my health care information to be released to the following recipient:

 PO Box 4562, Charlottesville, VA 22905
 Phone: 434-234-7676 
 Fax: 434-333-7560

Purpose:  I authorize the release of my health information for the specific purpose of participating in the BEATDiabetes program. This information will be used for continuation of care within the program. 

Information to be disclosed:  I authorize the release of the following health information from 6 months prior to the date of this agreement to the end of the term on December 31, 2022:

  • Hemoglobin A1C blood test results

Term:  This Authorization will remain in effect from the date of this Authorization until December 31, 2022.

Redisclosure:  I understand that my health care provider cannot guarantee that the recipient will not redisclose my health information to a third party. 

Refusal to sign/right to revoke: I understand that signing this form is voluntary.  If I change my mind, I understand that I can revoke this authorization by providing a written notice of revocation.  The revocation will be effective immediately upon my health care provider’s receipt of my written notice, except that the revocation will not have any effect on any action taken by my health care provider in reliance on this Authorization before it received my written notice of revocation.