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Your employer encourages you to participate in the wellness program. You are given the option to complete a screening

through your physician. Please complete the following steps to ensure your results are received in a timely manner.

Both participant and physician signatures must be present to process results.

Submitting your Biometric Screening Results: 1. If you have already completed a biometric screening through your physician or medical provider on or after

September 1, 2015: a. Fill out the participant information section on the Screening Results Form, sign the form and leave all

pages of this document with your provider. Ask them to complete the Physician Information and Biometric Screening Results sections and return by following the instructions on page two of this document NO LATER THAN August 15, 2016. Your provider can also complete the form and return it to you to submit. Both participant and physician signatures must be present to process results.

2. If you choose to complete your biometric screening through your physician or medical provider:

a. Schedule an appointment with your provider before August 15, 2016. Tell them that you need a lipid panel, blood glucose or A1C, height, weight, waist circumference and blood pressure for your company wellness program and to code the visit as preventive care.

b. Fill out the participant information section on the Screening Results Form, sign the form and all pages of this document with your physician. Ask them to complete the Physician Information and Biometric Screening Results sections and return by following the instructions on page two of this document NO LATER THAN August 15, 2016. Your provider can also complete the form and return it to you to fax. Both participant and physician signatures must be present to process results.

c. It is your responsibility to make sure your provider or you submit forms on time.

Participants may complete either A1C or glucose testing, but needn’t complete both in order to earn credit.

ALL RESULTS MUST BE ENTERED INTO THE APPROPRIATE BOXES ON THE SCREENING RESULTS FORM. SEPARATE FORMS AND/OR ATTACHED LAB REPORTS CANNOT BE REVIEWED OR PROCESSED.

Visit the Wellness Portal to access your Personal Wellness Report once your results have been processed. Your Personal

Wellness Report includes your screening and Wellness Assessment results, along with recommended next steps. Please

allow 5-7 business days for the form to be processed. If you have any questions, please contact your employer’s

Wellness Contact or Accountable Health Solutions at 877-475-3442, select option #4.

PARTICIPANT CONSENT Participants must read consent language below and sign the consent statement on the Screening Results Form. I understand that Hooper Holmes, Inc. and Accountable Health Solutions, LLC., collectively, the (“Providers”) are not responsible for diagnosing, treating, or preventing

any medical disease or condition that I currently have or may have in the future. I also understand that the Providers will not give me medical advice and that I must

seek such advice from my own physician. The Providers have agreed with your employer that they will not use or disclose your health information except as permitted

or required by HIPAA and their applicable Business Associate Agreements. Finally, I understand that I may faint, bruise, or have other effects as a result of my blood

being drawn. I voluntarily agree and consent to participate in the health screening and accept and assume all risks associated with such participation. I hereby

release and forever discharge the Providers, including their owners, employees, and agents from any and all claims, demands, actions, and damages, including

attorney’s fees and costs, arising out of or in any way related to my participation in the health screening or wellness program.

Please provide your physician with the instructions on page 2 of this document

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ATTENTION HEALTH CARE PROVIDER:

Your patient is a participant in a health and wellness program sponsored through their employer. Through this wellness

program, your patient has an opportunity to improve their health risk as they exhibit healthy lifestyle choices.

Please complete the following:

1. Ensure the patient has completed and signed the participant section on the Screening Results Form.

2. Collect the biometric measurements, blood specimen and complete the remaining sections of the Screening Results

Form by following the instructions below.

ALL RESULTS MUST BE ENTERED INTO THE APPROPRIATE BOXES ON THE SCREENING RESULTS FORM.

SEPARATE FORMS AND/OR ATTACHED LAB REPORTS CANNOT BE REVIEWED OR PROCESSED.

3. Fax the completed Screening Results Form to 1-855-827-6307 OR email to PhysicianForms@ahs-hh.com.

4. Provide a copy to the participant.

Please follow the guidelines below when collecting the biometric measurements:

• Height: Perform the height measurement using a sliding height measuring stick. Have the patient remove their

shoes and record to the nearest ¼ inch. Self-reported heights are not acceptable.

• Weight: Perform a weight measurement using a professional grade scale with a minimum capacity of 400

pounds. Have the patient remove their shoes and record. Do not make any adjustments for clothes.

• Waist Circumference: Use a soft tape measure. For waist measurement, place the tape measure at the navel.

• BMI: Calculate using standard conversion chart for height and weight.

Manual Calculation: [weight / (height x height)] x 703

• Blood Pressure: Perform using a standard sphygmomanometer, cuff size as appropriate.

Billing:

• Make sure services are properly coded as preventive, not diagnostic.

• Submit invoices to the address on the patient’s Health Insurance Card.

Physician Wellness Screening Results Form Participant Information (completed by patient - Please Print)

Release of Health Information:

Participant Signature (REQUIRED):

Date:

Physician Information

Please complete this section for the above patient (please print).

Biometric Screening Results (completed by physician)

Physician’s Signature (REQUIRED): ______________________________________________ Date: ______________

Physician’s Name (please print): ________________________________________

By submitting this form I am requesting my physician to report my biometric and laboratory results to Hooper Holmes Health & Wellness to be included as part of my employer sponsored wellness program. By signing below, I authorize the release of my personal health information and preventive health screening results listed on this form by my health care provider. This authorization shall remain in force for 12 months following the date of my signature below and a copy of this authorization is as valid as the original. I understand that I have the right to revoke this authorization in writing, at any time, by providing written notification.

Your patient is a participant in a health and wellness program sponsored through their employer. Through this wellness program your patient has an opportunity to improve their health risks as they exhibit healthy lifestyle choices. This program is not intended to treat, diagnose or replace physician involvement, but rather to create and promote an atmosphere of healthy living and learning through their employer’s wellness initiatives.

PCP Office: Fax completed form to Hooper Holmes at 1-855-827-6307

IMPORTANT: PLEASE READ BELOW - Health Coaching Consent - Accountable Health Solutions

FIRST NAME MIDDLE INITIAL

EMPLOYER NAME SPONSOR NAME

LAST NAME

ADDRESS

BIRTH DATE

M FGENDERPHONE NUMBER

CONTACT NAME

ADDRESS

STATE ZIPCITY

STATE ZIPCITY

PHYSICIAN NAME/CLINIC PHONE NUMBER

EXAMINATION DATE

WEIGHTLBS.

TOTAL CHOLESTEROL LDL

HEIGHTFT. IN.

BLOOD PRESSURE mmHg TRIGLYCERIDESHOURSFASTED

GLUCOSEHDLWAIST (IN.) BMI

Original Copy – Physician Fax to 1-855-827-6307 W2035 V. 06/12/15

EMAIL

YES! Please enroll me in the Health Coaching program offered by my employer through Accountable Health Solutions. If I qualify, contact me to get started. I understand that my eligibility for the Health Coaching program is determined by the results of my screening (and Wellness Assessment, if applicable).I am not sure. Please contact me to discuss my options for Health Coaching offered by my employer at no cost to me. I understand that I can enroll in the program in the future as long as I meet the eligibility conditions determined by my employer.

PREFERRED PHONE WORKHOMEMOBILE

During what time frame would you prefer to have your first 15 minute Health Coaching phone call? (We will use the preferred phone number you have provided above.)

8:00 am - 9:00 am9:00 am - 12:00 pm12:00 pm - 3:00 pm

3:00 pm - 6:00 pm6:00 pm - 8:00 pm8:00 pm - 9:00 pm

Would you prefer a Spanish-speaking Health Coach? No Yes

A H S

1/4

3/4

1/2

even

1/4

3/4

1/2

even

.

FILL

ABLE

.(May differ from portaldue to rounding)

C H I L D R E N S W I S C