GEMCARE WELLNESS PARTICIPANT NOTICE AND CONSENT
This Participant Notice and Consent authorizes GemCare Wellness, and any sub-contracted vendors, and/or other partners engaged by my Employer’s health plan to conduct services in connection with my Employer’s wellness program (the “Program”).
By executing this Participant Notice and Consent, I am voluntarily authorizing the use and disclosure of health and personal information for purposes of my participation in the Program. I have carefully read this Participant Notice and Consent to understand my rights.
- I hereby authorize GemCare Wellness health coach’s access to any health information that will allow them to create a “Care Plan” for the purposes of providing me direction and information to improve my health status. Their sole purpose for accessing this information is to provide me health information and health outreach.
- I understand that my health information, including my “Care Plan” will not be shared with my employer.
- I understand that my participation in this program may be used to determine my available rewards.
- In the event of a termination of the services provided by GemCare Wellness under the Program, I authorize that GemCare Wellness may send the data and information collected or created to another wellness administrator or health plan to maintain the continuity of information for my participation in the Program.
- I have read and understand the following statements about my rights:
- I may revoke this authorization at any time by notifying GemCare Wellness, in writing, but revocation will not have any effect on any actions that the GemCare Wellness took before receiving the revocation.
- I may receive a copy of the information described on this form upon request.
- The information that is used or disclosed pursuant to this authorization may be re-disclosed by the receiving entity as described above.
- I understand that any participation in this Program is voluntary and that enrollment in or eligibility for health plan benefits is not conditioned upon providing this authorization. By participating in the Program and screening events, I hereby accept all risk to my health that may result from such participation except in the case of gross negligence and I hereby release and agree to hold harmless my employer, my employer’s insurance agent, my employer’s selected vendors, GemCare Wellness, its affiliates, and their respective officers, directors, employees, agents, successors and assigns from any and all liability to myself, my personal representatives, estate, heirs, next of kin and assigns, from any and all claims and causes of actions for all illness or injury to my person resulting from my participation in the Program.
- Consultation with Physician: This Program is not a diagnostic tool; it does not provide, nor is it a substitute for, professional medical advice, diagnosis or treatment. The Program recommends consultation with your healthcare professional for such services. The information provided by the Program is for educational purposes only and should not be interpreted as a diagnosis or as a recommendation for a specific treatment plan, product, or course of action.
- Terms of Agreement: Unless participation in the Program is terminated by you or your employer, this Agreement remains in effect for as long as your employer elects to participate in the Program.
- This Agreement shall be governed by and construed according to the laws of the State of Ohio, without giving effect to conflict of law principles. Any provision of this Agreement found to be invalid by a court having competent jurisdiction shall not affect the validity of the remaining provisions of this Agreement. No waiver of any term or condition of this Agreement shall be deemed a continuing waiver of such term or condition or any other term or condition.
I have carefully read this agreement and understand the terms and conditions of my voluntary participation in the Program. I have read the GemCare Wellness Participant Notice and Consent as of the date signed below or electronically recorded by the online registration system.