Annual Screening

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Name* This field is required.

First Name

Last Name

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Email Address* This field is required.

example@example.com

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Wellness Program Insurance Plan Eligibility* This field is required.I understand and agree that in order to receive the discounted rate for the Wellness Insurance Plan, I must meet ALL wellness program requirements by the deadline of May 1, 2026. I understand that eligibility for the Wellness Insurance Plan includes the following requirements: 1) Completion of a biometric screening and health risk assessment and 2) Earning at least 50 wellness credits by participating in eligible activities as outlined in the Wellness Program Handbook. I understand that my failure to complete these requirements by the May 1, 2026 deadline will forefit my ability to enroll in the Wellness Insurance Plan in the upcoming open enrollment period and must be earned again the following year.

YESNO

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Privacy Disclaimer and Informed Consent:* This field is required.I consent to have Working Well, LLC administer each of the following screenings: (1) Total Body weight analysis (2) Health/Disease Risk Assessment (data collection by Working Well, LLC) (3) Blood pressure analysis (automated BP cuff or manual cuff) (4) Blood cholesterol (lipid profile) and blood glucose levels taken via finger stick for onsite analysis I understand that there are possible risks associated with taking a blood sample by finger stick, including but not limited to the risk of bruising of the finger, infection, and fainting due to the sight of blood. I understand that: I am entitled to receive a copy of this Informed Consent, my health screening results, and any other protected health information that is collected by Working Well, LLC in connection with my health screenings. The chemical analyzer used to determine cholesterol and glucose levels may yield results that are not as accurate as those produced by laboratory analyzers. A diagnosis can only be made by a qualified physician or licensed healthcare professional. The test results collected here by Working Well, LLC will be held securely and confidentially by Working Well, LLC. The results of your screening will not be shared with your employer or company, other than in a de-identified data report to show overall risk categories and test results. Non-specific information, including your name and department, will be sent to your employer solely for the purpose of confirming that you have or have not met eligibility requirements for the company Wellness Program Insurance Incentive. Your test results (without identifying information) will be used as part of an aggregated data report so that the Wellness Coordinator of Working Well, LLC can design health promotion programs to meet employees’ needs. Your test results will not be used by Working Well, LLC for purposes of individual health information or to make a diagnosis of any disease or illness. Working Well, LLC is a Personal Wellness and Health Education company that provides information and support as part of your employer’s Wellness Program. Working Well, LLC does not practice medicine and is not a substitute for your doctor’s care. You are responsible for contacting your primary care doctor for questions about any specific medical needs that may be indicated by these biometric screenings. I will not hold Working Well, LLC responsible for providing information, diagnosis or treatment as a substitute for the care I receive from my physician or other qualified healthcare provider. If I have an abnormal screening result, I am responsible for following-up with my primary care physician.

I agree to the above terms and conditions

I DO NOT agree to the above terms and conditions

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Signature* This field is required.

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