Healthcare Wellness Workdays

HEALTHCARE WELLNESS WORKDAYS

Event / Workday Details

Organizer / Employer:

Location:

Event Date:   Time:   On-site Clinician/Agency:

Patient Information

Insurance / Billing

Insurance Provider:

I decline insurance billing and will self-pay for services rendered.

Medical History / Screening

Chronic Conditions (check all that apply)

Diabetes    Heart disease    Hypertension    Asthma / COPD

Immunocompromised    Bleeding disorder    None of the above

Pregnant or trying to become pregnant

Services Requested / Offered

Select services to be provided at this wellness workday (check as applicable):

Blood pressure screening    Blood glucose screening    Cholesterol screening

BMI / weight counseling    Vaccination (influenza, other)    TB screening

Laboratory specimen collection    Health counseling / referrals    Other:

Vaccination Screening (if applicable)

Please answer the following truthfully. A "yes" response may require further assessment before vaccination.

Are you currently ill with fever or an acute infection?   Yes   No

History of severe allergic reaction to a prior vaccine or vaccine component?   Yes   No

Currently pregnant or breastfeeding?   Yes   No

Consent, Authorization and Acknowledgments

I hereby request and consent to receive the selected screening and/or vaccination services provided during the Healthcare Wellness Workday. I understand that services are voluntary and that the clinician will explain the nature, benefits, and potential risks of any procedure or vaccination prior to administration. I acknowledge the opportunity to ask questions and to decline any recommended service.

I authorize the clinician and associated staff to perform the selected procedures and to take necessary steps in the event of an adverse reaction, including emergency care and transportation if required. I understand that reputable attempts will be made to notify my emergency contact as listed on this form.

I authorize the release of pertinent medical information to my insurance carrier for the purpose of billing when applicable, and to the organizing entity for de-identified, aggregate reporting of wellness outcomes. I understand that individually identifiable health information will not be disclosed to my employer without my separate written authorization, except as required by law.

By signing below I certify that the information I have provided on this form is true and complete to the best of my knowledge. I understand that withholding information may increase the risk of injury or adverse outcome. I release the clinicians and organizing entity from liability for routine care provided during the event, except in cases of gross negligence or willful misconduct.

Privacy / HIPAA Acknowledgment

I acknowledge receipt of the privacy notice describing the use and disclosure of my protected health information for treatment, payment, and health care operations. I authorize the clinician to use and disclose my protected health information as necessary to provide the services requested and for billing purposes. I understand I may request restrictions and that such requests will be considered in accordance with applicable law.

Authorization Duration and Revocation

This authorization to provide care and to release information for the purposes set forth on this form shall remain in effect for the date of the event and for thirty (30) days thereafter, unless I revoke this authorization earlier in writing. To revoke, I must submit a written request to the clinician or organizing entity; revocation will not affect actions already taken in reliance on this authorization.

Authorization expiration date (if different from default):

Provider Notes (Clinical Use)

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