Healthcare Incentive Program Agreement

HEALTHCARE INCENTIVE PROGRAM AGREEMENT

This Healthcare Incentive Program Agreement (Agreement) governs Participant enrollment in the incentive program identified below and authorizes use and disclosure of Health Information as necessary to administer the program. Program Name: . Sponsor/Plan/Employer: . Program Start Date:

Participant Information

Date of Birth:   Gender: Male Female Other

Emergency Contact

Insurance Information

Medical History (for eligibility assessment)

Incentive Description and Payment Terms

Eligible incentive(s): Gift card Premium reduction Other:

Eligibility, Verification and Appeals

Participant acknowledges that incentive eligibility is conditioned on satisfaction of program criteria, documented verification of completion of required activities, and any applicable waiting periods. Verification may require review of claims, provider attestations, laboratory results, or plan records. Participant consents to such verification by checking the box below.

I consent to verification of my enrollment, claims, and clinical records as necessary to determine incentive eligibility.

Authorization to Use and Disclose Health Information (HIPAA Authorization)

I authorize the release and disclosure of my Protected Health Information (PHI) to the Program Administrator, Sponsor, and their agents to the extent necessary to determine eligibility, administer incentives, and process payments. PHI to be disclosed may include dates of service, diagnoses, treatment codes, laboratory results, and claims information relevant to program requirements. This authorization does not authorize unrelated disclosures of psychotherapy notes.

I understand that information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal privacy laws. I understand I may revoke this authorization in writing, except to the extent that action has already been taken in reliance on it.

I acknowledge receipt of this Authorization and understand the uses and disclosures described above.

Financial and Tax Acknowledgement

Participant acknowledges that incentive amounts may be treated as taxable income under applicable law and that the Sponsor or Administrator may report payments or issue tax forms as required. Participant is responsible for any tax liability arising from receipt of incentives. Participant affirms that the payee/correspondence information provided is accurate.

I acknowledge responsibility for any tax reporting or tax liability related to incentives.

Termination, Amendment and Liability

The Sponsor or Program Administrator may modify or terminate the program at any time, subject to applicable law, provided that material changes will be communicated to Participants in writing. Termination of the program does not relieve Participant of obligations that accrued prior to termination. Except where prohibited by law, neither the Sponsor nor the Program Administrator shall be liable for indirect, incidental, or consequential damages arising from program administration; liability shall be limited to direct payments due under this Agreement.

Certifications and Representations

By signing below, Participant certifies that all information provided in this Agreement is true, complete, and accurate to the best of Participant's knowledge. Participant agrees to comply with program rules and to notify the Program Administrator of any changes that may affect eligibility.

Governing law: . This Agreement constitutes the entire agreement between the parties with respect to the subject matter herein.

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