Informed Consent and Release of Liability:
I request the opportunity to participate in a health screening and personal wellness profile conducted by the Wellness Department at St. Peter's Hospital. The screening involves the drawing of blood for laboratory testing, measuring blood pressure, and other simple tests. I understand that my participation is entirely voluntary, and that I may stop the evaluation at any point.
I understand that there may be variances in test results, and that I should consult with my physician for a comprehensive analysis of my physical condition or any symptoms I may be experiencing. I also understand that the tests which are to be conducted are screening procedures only, not diagnostic in nature, and the laboratory results do not predict the future. I realize that all results are kept confidential, and that it is my responsibility to follow up on any abnormal result with my health care provider.
I understand that I am encouraged to ask questions to request further information about the procedures used in this screening and evaluation. I have read and I understand the testing procedures that will be performed.
I recognize and accept any risk associated with my participation in this health screening and I release St. Peter's Hospital from all liability, medical claims or expenses which may arise from my participation, or from any injury sustained during this event.
Authorization for Release of Protected Health Information for purposes of Health plan copay only:
My Protected Health Information (PHI) is individually identifiable health information, including but not limited to information collected from me or created or received by a health care provider, a health plan, my employer, or health care clearing house that relates to: (i)my past, present or future physical or mental health condition; (ii) the provision of health care to me including preventative care; or (iii)the past, present or future payment for the provision of health care to me.
By signing this form I hereby authorize SD#1 Plan Administration and its affiliates to use and disclose my PHI as it has been defined above. I acknowledge that if I am NOT covered under the SD#1 health benefits plan I will be responsible for the full charges of the screening. This authorization is given for the purposes of participating in SD#1's bona fide wellness program. I understand that I am under no obligation to sign this release and that the terms and conditions of my employment or eligibility for SD#1 Group Health Plan will NOT be based on this information nor upon my willingness or unwillingness to release this information. I also understand that if I refuse to sign this release that SD#1 may not grant the financial benefits that are offered in conjunction with the SD's bona fide wellness program.
I understand that I may revoke this Authorization at any time by sending a written notification to SD#1, Attn: Human Resources, 55 S. Rodney, Helena, MT 59601. In the event that I revoke this release, this revocation will not apply to information already disclosed or released. Unless otherwise revoked, this Authorization will expire in eighteen (18) months.