Healthy Heart Ambassador Registration Form
Healthy Heart Ambassador (HHA) Blood Pressure Self-Monitoring Program
What is the Healthy Heart Ambassador Blood Pressure Self-Monitoring Program (HHA program)?
The Healthy Heart Ambassador Blood Pressure Self-Monitoring program is a 4-month program that includes 10-minute consultations with a program facilitator during drop in office hours, weekly check-ins from the program facilitator by phone, email or text, and monthly nutrition education seminars. Program participants are asked to attend two personalized consultations per month (office hours) as well as the monthly nutrition education seminars.
How do you benefit the HHA program?
• Investment in your health and a commitment to reducing your risk for heart attack or stroke • Receive support to develop the habit of self-monitoring to lower or better manage your blood pressure • Ensures the program is sustainable and can benefit others who have high blood pressure • Access to nutrition classes • Receive a FREE T-shirts • Receive other giveaways!
Qualifications to enroll in the HHA program:
• Be at least 18 years old or older • Been diagnosed with high blood pressure and/or are on antihypertensive medication. • Not experienced a recent (within the last 12 months) cardiac event. • Not have atrial fibrillation or other arrhythmias. • Not have or are not at risk for lymphedema
Once you've read the above statements, please fill out the below
Name
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First Name
Last Name
Date of Birth
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-
Month
-
Day
Year
Date
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you have a Primary Care Provider?
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Yes
No
Primary Care Provider
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First Name
Last Name
PCP's Phone #
Please enter a valid phone number.
Please select all that apply
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I am at least 18 years old
I HAVE been diagnosed with high blood pressure and/or are on antihypertensive medication
I HAVE NOT experienced a recent (within the last 12 months) cardiac event
I HAVE NOT had atrial fibrillation or other arrhythmias
I HAVE NOT had or are not at risk for lymphedema
What benefits are you hoping to attain through this program?
Read the beginning of the form for more information regarding benefits of the HHA Blood Pressure Self-Monitoring program.
Do you have insurance?
Yes
No
Program Referral Options
How would you like to be referred into the program
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Option 1: Through our Clinical Partner, JenCare of Forest Park.
Option 2: Have our Health Access Team contact your primary healthcare provider.
Option 3: Electronically submit your referral with your primary healthcare provider.
Option 4: Fax your referral with your primary healthcare provider.
Option 1
A Health Access Team Member from Hight Health will contact you through the contact information you provide on this form.
You will then be connected to JenCare Forest Park to set up your enrollment visit. *Please note, the JenCare enrollment visit is only to ensure you meet the program qualifications and to receive a physician referral.
Option 2
A Health Access Team Member from Hight Health will contact you through the contact information you provide on this form.
Complete the HIPAA form, giving Hight Health approval to contact your healthcare provider to get a referral.
Hight Health will work with your healthcare provider to obtain your last office visit notes, showing the appropriate codes for a hypertension diagnosis.
A Healthy Heart Ambassador will contact you about enrollment once the referral form is received from your healthcare provider.
Option 3
Share this HHA referral form link with your medical provider:
https://form.jotform.com/231234707980053
Your medical provider will fill in the information and electronically sign and submit this form.
You are also required to sign this form. If you are unable to sign at the time your medical provider is submitting this form, the Healthy Heart Ambassador can obtain your signature on a later date.
Once your medical provider submits this form, attesting that you meet all medical requirements, a Healthy Heart Ambassador will contact you to begin full enrollment in the Healthy Heart Ambassador Blood Pressure Self-Monitoring Program!
Option 4
Click this link to access the HHA Blood Pressure Self-Monitoring Provider Referral Form:
https://form.jotform.com/231234707980053
Scroll to the bottom of the HHA referral form and click 'Print'.
Take the blank HHA referral form (2 pages) to your medical provider to complete and sign.
You or your medical provider can submit the HHA referral form to Hight Health via:
Email: hha@hight.health
Fax: (404) 614-0710
In-person: Contact hha@hight.health to coordinate.
Once your completed HHA referral form (attesting that you meet all medical requirements) is received, a Healthy Heart Ambassador will contact you to begin full enrollment in the Healthy Heart Ambassador Blood Pressure Self-Monitoring Program!
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Attestation
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I hereby attest that, to the best of my knowledge, the providedinformation is true and accurate.
Please verify that you are human
*
Thank you!
Please check your email for next steps.
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