City of Plano Biometric Screening Options

Voucher Request

Disclaimer

I wish to participate in the screening program being offered by US Wellness, Inc, the test provider. By signing this consent form, I understand that I am requesting and agree to allow US Wellness send me laboratory voucher and for US Wellness to receive my screening results from the laboratory performing the screening.

  • I understand that a screening does not replace a consultation, physical examination, or evaluation from my physician or other appropriate healthcare provider.
  • I understand that this screening may generate an inaccurate result. I will discuss my screening results with my physician and will not use my result as an indicator for medication dosing, such as insulin.
  • I understand that the recommendation to contact my physician about the result of the screening is not a medical diagnosis or assessment of good health as only my own physician can make such a judgment and more information would be needed to establish or rule out a diagnosis or assessment of good health.
  • I understand that participation in this screening will not protect me from disease.
  • I understand that regardless of the results of this screening and consultation, my overall health is affected by cigarette smoking, family history of disease, hypertension and excess weight, and that I should discuss these risk factors with my own physician.
  • I understand that I am responsible for any follow-up examinations with my physician that may be indicated from the results of this screening.
  • I understand that any genetic information collected by US Wellness will be treated as strictly confidential in accordance with requirements of the Genetic Information Nondiscrimination Act of 2008 (GINA).

I hereby release US Wellness, Inc., Plan IT, and their affiliated and subsidiary companies, divisions, directors, officers, employees, agents and contractors and any and all other organizations involved in the program, and their affiliates and subsidiaries, and all of their past and present officers, employees and agents, and the successors of each, from any liability and responsibility for any and all manner of actions, causes of action (individual and class),  claims or demands of any kind whatsoever, whether known, suspected or unknown, in law or in equity including, but not limited to, all claims or potential claims arising out of my voluntary participation in or any injury, loss or death sustained from or arising as a result of,  this screening program, and any claim that this screening failed to identify or incorrectly identified any health condition.

I hereby authorize that any individually identifiable health information about me obtained in the course of this screening may be maintained by US Wellness, Inc., and Plan IT for uses and disclosures permitted of covered entities under the federal HIPAA Privacy Rule.  I hereby authorize that US Wellness and Plan IT may contact me about health and wellness matters and acknowledge that personal health information can be accessed by designated individuals within my employer for the purpose of administering the wellness program. By signing below, I acknowledge that I have read, understand, and accept all of the statements on this consent form.

 Date Format: YYYY-MM-DD