ADA/GINA Notice
Purpose of the Wellness Program.
Your (spouse’s) employer has established a voluntary wellness program in conjunction with the employer-sponsored medical group health plan (“Group Health Plan”). The goal of the Wellness Program is to improve health or prevent disease in participants. It is not designed to be overly burdensome or a subterfuge for violating the Genetic Information Nondiscrimination Act (“GINA”), the Americans with Disabilities Act of 1990 (“ADA”), the Health Insurance Portability and Accountability Act (“HIPAA”), or other federal laws.
Your Participation is Voluntary.
The Wellness Program is a voluntary wellness program available to all eligible employees. Failure to sign this Authorization will in no way affect your ability to obtain treatment, payment, or eligibility for health coverage under the Group Health Plan. Further, your (spouse’s) employer may not take any adverse action against you for non-participation in the Wellness Program.
If you choose to participate in the Wellness Program, you may be asked to complete a voluntary health risk assessment or "HRA" that asks a series of questions about your health-related activities and behaviors and whether you have or had certain medical conditions (e.g., cancer, diabetes, or heart disease). You may also be asked to complete a biometric screening, which may include a blood test. See Information Released, below. You are not required to complete the HRA or to participate in the blood test or other medical examinations in order to be eligible for medical coverage. However, employees who choose to participate in the Wellness Program will have the opportunity to receive an incentive.
Although you are not required to complete the HRA or participate in the biometric screening, only employees who do so will be eligible to receive the incentive. See your Wellness Materials or contact the Plan Administrator for the Wellness Program incentives and how each is achieved.
If you are unable to participate in any of the health-related activities or achieve any of the health outcomes required to earn an incentive, you may be entitled to a reasonable accommodation or an alternative standard. You may request a reasonable accommodation or an alternative standard by contacting iaWellness at 806-765-7265, 8206 Vicksburg Ave, Lubbock, Texas 79424 or [email protected].
The information from your HRA and the results from your biometric screening will be used to provide you with information to help you understand your current health and potential risks. It may also be used to offer you services through the Wellness Program, such as Disease Management or Coach Calls. You also are encouraged to share your results or concerns with your own doctor.
Protections from Disclosure of Medical Information.
iaWellness is required by law to maintain the privacy and security of your personally identifiable health information (“PHI”). Although the Wellness Program and the employer may use aggregate information it collects to design a program based on identified health risks in the workplace, the Wellness Program will never disclose any of your PHI either publicly or to the employer, except as necessary to respond to a request from you for a reasonable accommodation needed to participate in the Wellness Program, or as expressly permitted by law. Medical information that personally identifies you that is provided in connection with the Wellness Program will not be provided to your supervisors or managers and may never be used to make decisions regarding your employment. You may not be discriminated against in employment because of the medical information you provide as part of participating in the Wellness Program, nor may you be subjected to retaliation if you choose not to participate
In addition, all medical information obtained through the Wellness Program will be maintained separate from your personnel records, information stored electronically will be encrypted, and no information you provide as part of the Wellness Program will be used in making any employment decision.
Your Protected Health Information Will Be Protected Under the HIPAA Privacy, Security, and Breach Notification Rules.
You have certain rights under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) to privacy regarding your protected health information. You have been informed of and given the right to review and secure a copy of the Group Health Plan’s Notice of Privacy Practices, which contains a more complete description of the permitted uses and disclosures of protected health information and your rights under HIPAA. Appropriate precautions will be taken to avoid any data breach, and in the event a data breach occurs involving information you provide in connection with the Wellness Program, we will notify you immediately.
Your health information will not be sold, exchanged, transferred, or otherwise disclosed except to the extent permitted by law to carry out specific activities related to the Wellness Program. You will not be asked or required to waive the confidentiality of your health information as a condition of participating in the Wellness Program or receiving an incentive.
Anyone who receives your information for purposes of providing you services as part of the Wellness Program will abide by the same confidentiality requirements. The only individual(s) who will receive your personally identifiable health information is (are) [iaWellness Registered Nurses, Dietitians, Exercise Sport Specialists, Account Managers and Covenant Screening Team Members.] in order to provide you with services under the Wellness Program.
Who Will Receive My PHI and Why?
iaWellness will use your PHI in administering the Wellness Program established by the Group Health Plan. iaWellness will provide participant coaching and customized group reports on an individual and group basis, and it needs your PHI to do so. iaWellness may release PHI to the Plan Sponsor only in aggregate (de-identified) form, except as needed to administer the Plan. The Plan Sponsor will abide by the HIPAA Privacy Rules. In the event iaWellness is no longer the administrator of the Wellness Program, iaWellness will obtain consent from you prior to transferring PHI to the new wellness vendor, if any.
Information Released.
Your employer may seek information through the HRA, medical claims history from providers, or exams, for example, to detect high cholesterol, on my current or past health status so long as you are covered by the Group Health Plan and my completion is voluntary.
Information collected may include:
Any and all biometric screenings including but not limited to: Blood Pressure, Glucose, A1c, AST, ALT and Lipid Panel (Total Cholesterol, HDL, LDL, Triglycerides, Total Cholesterol to HDL Ratio), Percent Body Fat (Body Composition), Waist Circumference, Hip Circumference (Hip to Waist Ratio), Body Mass Index (Height to Weight Ratio), Pregnancy & Breastfeeding status, Nicotine use, and Diagnosis of or Taking Medications
for Heart Disease, Diabetes, High Blood Pressure and/or Elevated Cholesterol.
Authorization and Revocation.
By signing this Authorization, you understand that your PHI may be used and disclosed to certain parties, subject to HIPAA. Information disclosed pursuant to this Authorization may be redisclosed by the recipient. Some re-disclosures may not be protected by state law or by HIPAA. You understand that your medical information may be provided to your (spouse’s) employer only in aggregate (de-identified) form, except as needed to administer the Plan, and then, only the minimum necessary information may be disclosed. In this event, individually identifiable health information collected from or created about you will be protected under the HIPAA Privacy, Security, and Breach Notification Rules.
In order to carry out and implement the Wellness Program, you hereby authorize the parties performing the biometric screening and those parties housing your medical and pharmacy claims to release your health information to iaWellness, LLC, 8206 Vicksburg Avenue, Lubbock, Texas 79424.
You may revoke this Authorization at any time, but you must do so in writing and submit it to the following address: iaWellness, LLC, 8206 Vicksburg Avenue, Lubbock, Texas 79424. Revocation of this Authorization will take effect upon receipt of my written request, except to the extent that others have acted in reliance upon this Authorization.
You have a right to receive a copy of this Authorization.
This Authorization will expire in one year or sooner if revoked.
**If you have questions or concerns regarding this notice, or about protections against discrimination and retaliation, please contact iaWellness at 806-765-7265.
Your (spouse’s) employer has established a voluntary wellness program in conjunction with the employer-sponsored medical group health plan (“Group Health Plan”). The goal of the Wellness Program is to improve health or prevent disease in participants. It is not designed to be overly burdensome or a subterfuge for violating the Genetic Information Nondiscrimination Act (“GINA”), the Americans with Disabilities Act of 1990 (“ADA”), the Health Insurance Portability and Accountability Act (“HIPAA”), or other federal laws.
Your Participation is Voluntary.
The Wellness Program is a voluntary wellness program available to all eligible employees. Failure to sign this Authorization will in no way affect your ability to obtain treatment, payment, or eligibility for health coverage under the Group Health Plan. Further, your (spouse’s) employer may not take any adverse action against you for non-participation in the Wellness Program.
If you choose to participate in the Wellness Program, you may be asked to complete a voluntary health risk assessment or "HRA" that asks a series of questions about your health-related activities and behaviors and whether you have or had certain medical conditions (e.g., cancer, diabetes, or heart disease). You may also be asked to complete a biometric screening, which may include a blood test. See Information Released, below. You are not required to complete the HRA or to participate in the blood test or other medical examinations in order to be eligible for medical coverage. However, employees who choose to participate in the Wellness Program will have the opportunity to receive an incentive.
Although you are not required to complete the HRA or participate in the biometric screening, only employees who do so will be eligible to receive the incentive. See your Wellness Materials or contact the Plan Administrator for the Wellness Program incentives and how each is achieved.
If you are unable to participate in any of the health-related activities or achieve any of the health outcomes required to earn an incentive, you may be entitled to a reasonable accommodation or an alternative standard. You may request a reasonable accommodation or an alternative standard by contacting iaWellness at 806-765-7265, 8206 Vicksburg Ave, Lubbock, Texas 79424 or [email protected].
The information from your HRA and the results from your biometric screening will be used to provide you with information to help you understand your current health and potential risks. It may also be used to offer you services through the Wellness Program, such as Disease Management or Coach Calls. You also are encouraged to share your results or concerns with your own doctor.
Protections from Disclosure of Medical Information.
iaWellness is required by law to maintain the privacy and security of your personally identifiable health information (“PHI”). Although the Wellness Program and the employer may use aggregate information it collects to design a program based on identified health risks in the workplace, the Wellness Program will never disclose any of your PHI either publicly or to the employer, except as necessary to respond to a request from you for a reasonable accommodation needed to participate in the Wellness Program, or as expressly permitted by law. Medical information that personally identifies you that is provided in connection with the Wellness Program will not be provided to your supervisors or managers and may never be used to make decisions regarding your employment. You may not be discriminated against in employment because of the medical information you provide as part of participating in the Wellness Program, nor may you be subjected to retaliation if you choose not to participate
In addition, all medical information obtained through the Wellness Program will be maintained separate from your personnel records, information stored electronically will be encrypted, and no information you provide as part of the Wellness Program will be used in making any employment decision.
Your Protected Health Information Will Be Protected Under the HIPAA Privacy, Security, and Breach Notification Rules.
You have certain rights under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) to privacy regarding your protected health information. You have been informed of and given the right to review and secure a copy of the Group Health Plan’s Notice of Privacy Practices, which contains a more complete description of the permitted uses and disclosures of protected health information and your rights under HIPAA. Appropriate precautions will be taken to avoid any data breach, and in the event a data breach occurs involving information you provide in connection with the Wellness Program, we will notify you immediately.
Your health information will not be sold, exchanged, transferred, or otherwise disclosed except to the extent permitted by law to carry out specific activities related to the Wellness Program. You will not be asked or required to waive the confidentiality of your health information as a condition of participating in the Wellness Program or receiving an incentive.
Anyone who receives your information for purposes of providing you services as part of the Wellness Program will abide by the same confidentiality requirements. The only individual(s) who will receive your personally identifiable health information is (are) [iaWellness Registered Nurses, Dietitians, Exercise Sport Specialists, Account Managers and Covenant Screening Team Members.] in order to provide you with services under the Wellness Program.
Who Will Receive My PHI and Why?
iaWellness will use your PHI in administering the Wellness Program established by the Group Health Plan. iaWellness will provide participant coaching and customized group reports on an individual and group basis, and it needs your PHI to do so. iaWellness may release PHI to the Plan Sponsor only in aggregate (de-identified) form, except as needed to administer the Plan. The Plan Sponsor will abide by the HIPAA Privacy Rules. In the event iaWellness is no longer the administrator of the Wellness Program, iaWellness will obtain consent from you prior to transferring PHI to the new wellness vendor, if any.
Information Released.
Your employer may seek information through the HRA, medical claims history from providers, or exams, for example, to detect high cholesterol, on my current or past health status so long as you are covered by the Group Health Plan and my completion is voluntary.
Information collected may include:
Any and all biometric screenings including but not limited to: Blood Pressure, Glucose, A1c, AST, ALT and Lipid Panel (Total Cholesterol, HDL, LDL, Triglycerides, Total Cholesterol to HDL Ratio), Percent Body Fat (Body Composition), Waist Circumference, Hip Circumference (Hip to Waist Ratio), Body Mass Index (Height to Weight Ratio), Pregnancy & Breastfeeding status, Nicotine use, and Diagnosis of or Taking Medications
for Heart Disease, Diabetes, High Blood Pressure and/or Elevated Cholesterol.
Authorization and Revocation.
By signing this Authorization, you understand that your PHI may be used and disclosed to certain parties, subject to HIPAA. Information disclosed pursuant to this Authorization may be redisclosed by the recipient. Some re-disclosures may not be protected by state law or by HIPAA. You understand that your medical information may be provided to your (spouse’s) employer only in aggregate (de-identified) form, except as needed to administer the Plan, and then, only the minimum necessary information may be disclosed. In this event, individually identifiable health information collected from or created about you will be protected under the HIPAA Privacy, Security, and Breach Notification Rules.
In order to carry out and implement the Wellness Program, you hereby authorize the parties performing the biometric screening and those parties housing your medical and pharmacy claims to release your health information to iaWellness, LLC, 8206 Vicksburg Avenue, Lubbock, Texas 79424.
You may revoke this Authorization at any time, but you must do so in writing and submit it to the following address: iaWellness, LLC, 8206 Vicksburg Avenue, Lubbock, Texas 79424. Revocation of this Authorization will take effect upon receipt of my written request, except to the extent that others have acted in reliance upon this Authorization.
You have a right to receive a copy of this Authorization.
This Authorization will expire in one year or sooner if revoked.
**If you have questions or concerns regarding this notice, or about protections against discrimination and retaliation, please contact iaWellness at 806-765-7265.
