LCC Employee Health Questions | St. Peter's Health

LCC Health Questions

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Name

First Name (Legal)

Last Name (Legal)

Birthdate

Employment Status-Please select from the following options:

1. Do you have a primary care provider?

If yes, please list:

2. Have you smoked in the last 3 months?

3. Have you used smokeless tobacco in the last 3 months?

4. Have you used e-cigarettes (vaped) in the last 3 months?

5. How many days per week do you get 30 min or more (at least 10 min at a time) of light to moderate physical activity?

6. Over the last 2 weeks, how often have you been bothered by little interest or pleasure in doing things?

7. Over the last 2 weeks, how often have you been bothered by feeling down, depressed or hopeless?

8. Have you had a dental exam in the last 12 months?

9. Have you had an eye exam in the last 12 months?

10. If over 50, have you had a mammogram (for women) or prostate test (men)?

11. Have you or anyone else in your immediate family had colon and/or breast cancer?

12. Has either of your parents had cardiovascular disease?

13. Have you been diagnosed by a provider with Type 2 diabetes?

14. Have there been significant changes to your health in the last year?

15. If over 50, have you had a colonoscopy?

16. Are you currently taking blood pressure medication?

Review Consent and Release of Liability

Informed Consent and Release of Liability

Informed Consent and Release of Liability:

I request the opportunity to participate in a health screening and personal wellness profile conducted by the Wellness Services of St. Peter's Health. 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 understand that I will receive communications in regards to my wellness participation by phone, SMS message (optional, normal rates apply) and email. These communications may be from third party platforms including, but not limited to: AppointmentPlus and Constant Contact.

I recognize and accept any risk associated with my participation in this health screening and I release St. Peter's Health 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 financial incentives 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 Allegiance Benefit Plan Administration and its affiliates to use and disclose my PHI as it has been defined above.This authorization is given for the purposes of participating in Lewis and Clark County's bona fide wellness and healthy lifestyles 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 Lewis and Clark County's 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 Lewis and Clark County may not grant the financial benefits that are offered in conjunction with the County's bona fide wellness program.

I understand that any disclosure of information carries with it the potential for an unauthorized re-disclosure and this information may not be protected by federal privacy rules. I understand that I may revoke this Authorization at any time by sending a written notification to Lewis and Clark County, Attn: Human Resources, 316 N. Park, rm 302, Helena, MT 59623. 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.

I have read and agree to the Consent and Release of Liability.

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.

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