Engagement Incentive Affidavit Form
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1
2Broward County Human Resources Division
Employee Benefit Services Section
115 S Andrews Avenue, Ste. 514, Fort Lauderdale FL 33301
Office: 954-357-6700 | Secured Facsimile: 954-728-2777
Email: | Website:
2016 E
I
A
NGAGEMENT
NCENTIVE
FFIDAVIT
Broward County’s medical plans are designed to encourage healthy lifestyles and engage members in actively managing their own health
care. Preventive screenings/exams and tests are free and can help find problems before they start, or at an early stage when the chances
for treatment and cure are better. In order to keep the plans affordable, it is important for all members to take an active role in their
health and wellbeing. The aggregate data also helps to design future benefit and wellbeing programs that may improve enrolled
members’ health and wellness.
Annual preventive services (provided at no cost in-network to plan members), play a key factor in early detection of chronic and life
threatening diseases. In recognition of the important for annual preventive screenings, the County is continuing the Engagement
Incentive for 2016. To receive the County-funding for the Health Reimbursement Account (HRA) or Health Savings Account (HSA), all
employees and enrolled spouses/registered domestic partners (DP), must complete one of the activities on the reverse side of this form,
per person, and submit the completed 2016 E
I
A
. See reverse side of this form for additional information.
NGAGEMENT
NCENTIVE
FFIDAVIT
NEW: Deadline to complete preventive screening is March 31, 2016 to receive 2016 County HRA or HSA funding. Newly benefit-eligible
employees with benefits effective January 1, 2016, or later, are exempt from the requirement during their first year.
Employee Last Name: ________________________________ First Name: ______________________________
Employee ID#: _______________________________ Spouse/DP’s Name: _______________________________
Is this form for:
Employee
Spouse/Registered Domestic Partner
Qualified Preventive Screening OR Humana Vitality Check & Health Assessment
Please use this side if you are/were a Humana Health Plan Member at the time of service.
If not, please use the reverse side of this form.
Complete this section by checking all that apply and noting the date of the screening/exam/Vitality Check. (Dates of service may be found
by logging in to or contacting a Humana on-site representative.)
___ I have completed the online Health Assessment & Vitality Check
Date: ________________________
___ I have completed a Qualified Preventive Screening Service in the
Date: ________________________
last 12 months.
Type of Screening/Exam Received: ______________________________________________________________
By signing this document, you agree to allow your medical care provider and/or Humana Health Plan to provide your name and verification of completion
of Preventive Screening Services and/or Vitality Check and online Health Risk Assessment to the Broward County, Employee Benefit Services Section as
required to authorize release of the County-funded applicable HRA/HSA funds. If you would like to revoke this authorization at any time, written notice
must be provided to the Broward County, Employee Benefit Services Section. However, any actions taken by Broward County, Employee Benefit Services
Section in reliance on your authorization before you revoked it will not be affected by the revocation.
Member Signature: _____________________________________________ Date: ________________________
Complete and return this form to:
Broward County Employee Benefit Services | Governmental Center, Room 514
Secured Fax: 954-728-2777 | Email:
Office Use Only: Information Verification
Humana Signature: _____________________________________________ Date: ________________________
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