NOTICE REGARDING WELLNESS PROGRAM WELLNESS PROGRAM SPOUSE/DEPENDENT AUTHORIZATION
The City of Cincinnati’s Healthy Lifestyles Program is a voluntary wellness program available to all Anthem plan members and their covered spouses. The program is administered according to federal rules permitting employer-sponsored wellness programs that seek to improve employee health or prevent disease, including the Americans with Disabilities Act of 1990, the Genetic Information Nondiscrimination Act of 2008 (GINA), and the Health Insurance Portability and Accountability Act, as applicable, among others. Under GINA, we are required to get authorization from covered spouses who participate in the wellness program if the wellness program provides an incentive in exchange for the spouse providing information about his or her past or current health status. If you choose to participate in the wellness program you will be asked to complete a voluntary personal health assessment or "PHA" 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 will also be asked to complete a biometric screening, which will measure your blood pressure, body mass index (BMI), waist measurement, and may include the collection of blood to determine cholesterol, glucose, and other results that are for information purposes only. You will not be asked for your genetic information. Your participation in the wellness program is voluntary. However, if you do not participate in the wellness program, you may not be eligible for certain wellness program incentives. If you are inadvertently asked to provide your genetic information, any earned incentives will be based solely on your provision of non-genetic information. You are not required to provide genetic information to qualify for any available incentive. The information from your PHA and the results from your biometric screening will be used to provide you with information to help you understand your current health status and potential risks and may also be used to offer you services through the wellness program, such as health coaching. You are encouraged to share your results or concerns with your own doctor. Confidentiality of Information We are required by law to maintain the privacy and security of your personally identifiable health information. The wellness program and City of Cincinnati may use aggregate information it collects to design a program based on identified health risks in the workplace. However, the wellness program will never disclose any of your personal information 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. Your personally identifiable 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, and 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 the purpose of providing you services as part of the wellness program will abide by the same confidentiality requirements.
Authorization
I have read and understand this authorization and wish to participate in the wellness program.
Spouse Name: ____________________________________ Employee Name:_____________________________
Spouse Signature & Date: ___________________________ Employee ID#: ______________________________
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