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Click here or scroll down to respond to this candidateFirst Name: Last Name: Property/Location Code: Employee 800 Number (or Benefit Plan ID):Date of Birth: Relationship:Candidate's Name
Gender:Male FemalePhone Number: Date:o Non-Fasting Results Health Metric My Current Numbers o Fasting ResultsWeight lbs.BMI/Body Fat Percentage BMI & BF% Waist CircumferenceBlood PressureTotal CholesterolHDLTC/HDL RatioGlucose/Blood SugarBIOMETRIC SCREENING FORMFollow these steps to receive credit for your participation in the Wellness Rewards Program: Street Address, City, State, Zip: Email Address:This Biometric Screening collects the health information identified below to help you manage your health and wellness under the Wellness Rewards Program. Caesars has implemented administrative safeguards to protect the confidentiality of your personal health information as required under the Health Insurance Portability and Accountability Act(HIPAA), Americans with Disabilities Act (ADA), and Genetic Information Nondiscrimination Act (GINA). Your participation is completely voluntary. However, if you choose not to participate, you may be ineligible for certain Wellness Rewards. Sign below to confirm your understanding and to authorize the collection of your Biometric Screening. Biometric Screening values reported on this form will be used to determine if you have earned a bonus reward for 2019. Participant Acknowledgement and Signature5. Return this form completed and signed to your onsite WellNurse by November 30, 2018. Note: Completed and signed forms may also be faxed to 855-816-3504 or emailed wellnessrewardsfax@cigna.com. 1. Biometric Screenings must be completed and returned between June 1, 2018 and November 30, 2018. 2. Complete your screening at either an onsite biometric screening event, at a property Wellness Clinic, with your WellNurse, or with an in-network provider. Check with ClearCost to find an in-network provider in your area! 4. Review your results. If your values are higher than those listed in the "Wellness Rewards Goals" section below please talk to your WellNurse about your Condition Management requirement. Newly benefits enrolled after 11/01/2018 must complete and submit their biometric screening by 5/31/2019. Please call the Wellness Rewards Customer Service Team at 800-591-9220 for information as your program requirements may be different. 3. A fully completed form and signature is required. Print all requested information clearly. Forms with information missing from either section will be returned for correction, which will delay your Wellness Rewards credit. Please call the Wellness Rewards Customer Service Team at 800-591-9220 for information on how to schedule your screening appointment. Section 1 - to be completed by participant: PARTICIPANT INFORMATION Required: if your screened values are above the Wellness Rewards Goals, completion of the Condition Management program may be required by 5/31/2019. Call 800-591-9220 for more information. Did the participant also complete an Annual Physical between June 1, 2018 and May 31, 2019? o Yes o No o N/A Date of Annual Physical: Provider Signature: Provider Name: Provider Signature: Title: Date: Phone Number: Special Notes to Participants: If you are pregnant, you do not need to complete a Biometric Screening. Please call the Wellness Rewards Customer Service Center at 800-591-9220 about the pregnancy process and how to receive Wellness Rewards credit. Provider or Lab Technician InformationParticipant Signature:Please check where you completed your biometric screening: Date of Screening:Blood Pressure: Less than 140 and 90Cholesterol: HDL Ratio Less than 4.0HeightBIOMETRIC SCREENING RESULTSGlucose: Fasting and Non-fasting less than 100 mg/dl Note to Provider: Please code this service as preventive. Your patient is participating in a special health awareness program called Wellness Rewards. Your patient has chosen to provide a Cigna WellNurse with proof of the below screenings to qualify for financial incentives from their employer. Any information you provide remains confidential between you, the patient, and Cigna. Please complete and sign this form so your patient can receive their rewards. Please send all biometric lab work to an in-network lab.Onsite Screening Event Cigna Clinic WellNurse Office Premise Health Clinic Primary Care PhysicianOther/Convenient Care Clinic(i.e. Walgreens): ft. in.Section 2 - to be completed by the provider: BIOMETRIC SCREENING BMI: Less than 28, or 10% weight loss, or Body fat % in desirable range based on age and genderWellness Rewards Bonus Goals:Participant InitialRevised: 5/1/2018 |
