Consent For Biometric Health Screening (Page 2 of 2) in pdf

AUTHORIZATION FOR USE AND DISCLOSURE OF MEDICAL INFORMATION

HEALTHY MIAMI PREMIUM DISCOUNT PROGRAM

TriHealth has been engaged by Miami University Health Plan (the "Plan") to provide biometric health screenings as part of the

Plan's Healthy Miami-Premium Discount Program (the "Program"). I authorize TriHealth, Inc. on behalf of its affiliates including

Bethesda Healthcare, Inc. (referred to hereinafter collectively as "TriHealth") to use and/or disclose my individually identifiable

health information as described below.

I understand it is a requirement of the Healthy Miami Premium Discount Program to have annual well visit with a primary care

physician. By completing the "physician information" below I authorize the named physician to receive my biometric health

screening results and the other information described on the health screening results form (e.g. blood test results) (collectively,

the "Biometric Health Screening Results").

I further authorize TriHealth to disclose my Biometric Health Screening Results to the Plan's designated third party in order for

such third party to: (1) make premium discount determinations for the Plan; and (2) create and report Aggregate Data to the Plan

for the Plan to assess population trends. "Aggregate Data" means a combination of my data with the data of other participants

in the Program that prevents the personal identification of me or any other participant.

I understand that my employer will

not receive nor have access to my personally identifiable health information as part of the Program. I further authorize

TriHealth to release my Health Screening Results to Cerner Wellness and The Advisory Board for the purposes of providing in-

person and on-line results to me, if I wish to do so.

TriHealth may not condition treatment on whether or not you sign this Authorization. If you refuse to sign this Authorization

TriHealth will not withhold treatment from you nor will your health plan enrollment or eligibility for benefits be affected.

understand that the information used and/or disclosed pursuant to this Authorization may be re-disclosed by the recipient of the

information and may no longer be protected by Federal law.

I understand that I may revoke this Authorization at any time by notifying TriHealth in writing by sending a letter to: Bethesda

Healthcare, Inc., 11129 Kenwood Road, Cincinnati, Ohio, 45242, attention of: Practice Administrator, Cynthia Traficant. I

understand that if I revoke this Authorization, it will not affect any actions that TriHealth took before it received my revocation

letter.

This Authorization will expire one year after the date below.

Physician Information

If you choose to participate in the Program in order to receive the full premium discount you must complete an annual

well visit with a physician. Your health screening results will be sent to your designated physician below.

Name of Physician (first and last): ___________________________________________________________________

Physician's address (Street/City/ Zip Code:_____________________________________________________________

Physician telephone number: ______________________________________________________

Physician FAX number: __________________________________________________________

PRINTED NAME OF PARTICIPANT: ______________________________________________________________

SIGNATURE OF PARTICIPANT: ___________________________________________DATE: ________________

Are there other health concerns you would like to share with your biometrics team today?

______________________________________________________________________________

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Consent For Biometric Health Screening Page 2