Consent for myHealth to Pull Biometrics from EPIC ... AWS

 

Consent for myHealth to Pull Biometrics from EPIC* To be completed by participant. All fields must be completed. Please PRINT. Incomplete/illegible forms may not be processed.

 2019 Wellness Incen ve: Form is due 05/31/18. Please allow 

me to 

complete Alternate Sa sfac on Ac vi es before October 31, 2018. 

It is the par cipant’s responsibility to submit this form.

  Submit completed form to:      submi ed and program requirements met within 6 months of hire or newly        Lakeland Care, Employer Services,  eligible date. If the par cipant has met all of the myHealth program requirements       1234 Napier Ave., St. Joseph, MI 49085  by the 15th of the month, the wellness incen ve will be applied on the first       or  Fax: 269‐408‐4523 or  Scan and e‐mail:                          paycheck of the following month. Please note, you will be eligible no sooner than       [email protected]  when your ini al insurance premium is deducted. 

 New Hire or Newly Eligible for Benefits: Biometrics must be    

Pa ent Name Lakeland Employee (if different than pa

ent)

E‐Mail Address

Associate Spouse

Male Female

Employee ID #

Pa ent Birth Date Phone

Consent to have biometrics extracted from EPIC:  I, ____________________________________________________(name), had a wellness visit on __________________________________ (date) with __________________________________________________ (Doctor/Provider’s name) I give permission for Lakeland Care to extract my biometrics from EPIC for the myHealth program. ________________________________________ Par cipant Signature

______________________________ Date

All biometric informa on provided is confiden al, protected by law and not disclosed to your employer.    DISCLOSURE: If it is unreasonably difficult due to a medical condi on for you to achieve the standards for the wellness incen ve under this program, or if it is medically inadvisable for you to a empt to achieve the standards for the wellness incen ve under this program, contact Lakeland Care at [email protected] to request a reasonable accommoda on to the Alterna ve Sa sfac on Ac vi es.   *NOTE: your provider must use EPIC as their Electronic Health Record for Lakeland Care to extract your biometrics. If your provider does not par cipate with EPIC, use the 2018/2019 PCP Wellness Visit Verifica on form. You will receive an email from myHealth regarding your status once your biometrics are collected. If you DO NOT receive an email within 5 business days of submi ng this form, please email [email protected]. 

Lakeland Care Administra on Use  

                    DM    BP: _________    Height: _______     Weight: _______     BMI: _________       HA1C Date: _________       HA1C: _________        

  myChart: ______         myLearning (associates only): ______         Wellness visit: ______         HRA: ______     Entered in Database: ______     Date Emailed/Ini als: ____________       Biometric Status: ___________    Revised 2018.1.17