Consent For Biometric Health Screening
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1
2HEALTHY MIAMI PREMIUM DISCOUNT PROGRAM
CONSENT FOR BIOMETRIC HEALTH SCREENING
I have been informed and I understand that my participation in the Healthy Miami Premium Discount Program (the "Program") is
completely voluntary. I understand that TriHealth, Inc. on behalf of its affiliates including Bethesda Healthcare, Inc. (“TriHealth”)
performs biometric health screenings as part of the Program on behalf of the Miami University Health Plan (the "Plan").
If I choose to participate in the Program I must obtain a biometric health screening and I hereby consent to the performance of
the following:
•
Blood pressure screening
•
Height and weight measure for purposes of calculating body mass index (“BMI”)
•
Complete a fasting blood draw for the purpose of performing the following screening tests:
Comprehensive Metabolic Panel
o
Lipid Panel
o
Complete Blood Count (CBC panel)
o
Iron, thyroid stimulating hormone (TSH), and if applicable colon health kit
o
HemoglobinA1c for fasting glucose over 100
o
The purpose of a biometric health screening is to evaluate selected physical measurements and lifestyle factors that help to
identify risk for potential health problems. I understand that the data derived from this screening is to be considered preliminary
only, does not constitute a diagnosis, and that this screening conducted under the Program is not a full medical exam. The
information provided to me through this screening is not intended to be a substitute for professional medical advice.
I understand that risks of the screening may include discomfort such as soreness, bruising or adverse reactions. I also
understand that it is my responsibility to disclose to the person conducting the screening any known allergies, medical
conditions, and medications I am taking prior to the assessment or screening.
I understand that the responsibility for initiating a follow-up examination to confirm results of any screening and obtain
professional medical assistance is mine alone, and not that of my employer, the Plan or TriHealth. If I display disease
symptoms, fall into certain high risk categories, or receive abnormal results, I am solely responsible for consulting my physician
before embarking on any course of action or lifestyle change.
I understand and agree that TriHealth is not liable for any health consequences resulting from my participation in the Program.
I affirm that I have read, understand, and agree to the terms set forth above and I wish to participate in the Program.
PRINTED NAME OF PARTICIPANT: ______________________________________________________________
SIGNATURE OF PARTICIPANT: ___________________________________________DATE: ________________
BIOMETRIC HEALTH SCREENING RESULTS
FASTING? Yes _____ No ______
Participant Information (Please Print):
Date of Birth _______/_______/_______
Age________
Select One: Male _________ Female _______
Select One: Employee ______ Spouse______ If Spouse, indicate Name of Employee _____________________________
Phone: _______________________ Email: _____________________________ Last 4 digits of SSN#: ________________
Colon Health Kit? Yes ___ No ____
(applicable for those age 50+ as of Dec. 31, 2016) Staff: colon kit ___yes ___no__ waive
IF NO LABEL - Complete this box
Staff Use Only
All info complete
Entered in to EMR
Last Name:
BP _________/__________ mmHg
First Name:
Height ________ ft_________in
Weight __________lb
Male
Female
Middle Initial
Optional:
Miami Unique ID
:
Hip Cir _____________ in Waist Cir _____________ in
31691350.4
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