By initializng this form you acknowledge that you have read and understand the following:

You may refuse to authorize and give consent. However, the testing that you are receiving today is being conducted for the purpose of having the results disclosed to your employer (participation only) and/or your employer’s insurance or health benefit plan for use in an employee wellness program. Therefore, I understand that I may refuse to authorize this form and in doing so will affect my ability to participate going further.

Parkview Workplace Wellness is a part of Parkview Occupational Health Centers, Inc. (POHC). I understand that results of tests obtained by POHC will be shared with my employer’s insurance or health benefit plan as part of an employee wellness program. I understand that the testing and results are based on guidelines provided to POHC by my employer. I hereby authorize Parkview Occupational Health Centers, Inc. to release my test results and all other information collected by POHC about me in connection with the testing and the guidelines for the employee wellness program to the MyWell-Being Portal or similar Health Risk Assessment Tool.

In the event that the information obtained includes reference to a mental health or drug and/or alcohol condition, treatment or diagnosis, I authorize the release of that information.

I understand that I may revoke this authorization at any time, except to the extent that POHC has already taken action in reliance on it. Unless revoked sooner, this authorization will expire one year from the date of my signature below. I also understand that information disclosed by POHC could be redisclosed by the recipient and might no longer be protected by HIPAA or any other privacy laws or regulations.

I understand that email is not secure. I nonetheless wish to receive my results via email. By including my email address above, I am requesting that my test results, measurements and my online health risk assessment log in instructions, if any, be sent to that email address.