Fillable EMPLOYEE/PRE-65 RETIREE ACKNOWLEDGEMENT OF THE REQUIREMENTS FOR WELLNESS (Columbus Consolidated Government)

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EMPLOYEE/PRE-65 RETIREE ACKNOWLEDGEMENT OF THE REQUIREMENTS FOR WELLNESS (Columbus Consolidated Government)

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Columbus Consolidated Government Healthcare Plan
EMPLOYEE/PRE-65 RETIREE ACKNOWLEDGEMENT OF THE REQUIREMENTS FOR
WELLNESS INCENTIVE OPTION
REQUIREMENTS FOR WELLNESS INCENTIVE OPTION FOR THE SILVER AND GOLD PLAN
To participate in the WELLNESS INCENTIVE OPTION, employees/Pre-65 Retirees on the Silver or Gold medical plan must do the
following:
1. Complete an on-site biometric screening provided by CareATC or your Primary Care Physician.
2. Participate in coaching if qualify as high risk.
Employees/Pre 65 Retirees covered by the COLUMBUS CONSOLIDATED GOVERNMENT MEDICAL PLAN who
participate in WELLNESS INCENTIVE OPTION will qualify for the premium credit for 2021. Your premium rate
will not increase.
All Personal Health Information (PHI) is confidential and will be managed in compliance with The Health Insurance
Portability & Accountability Act of 1996 (HIPAA) Privacy Rules where required by applicable law.
EMPLOYEE/PRE-65 RETIREE ACKNOWLEDGEMENT AND AGREEMENT FOR WELLNESS INCENTIVE OPTION
By completing the requirements for the Wellness Incentive Option, I understand that I will be eligible for the WELLNESS
PREMIUM credit. I understand and acknowledge that my failure to complete any requirements of the Wellness Incentive
Option will result in paying the NON WELLNESS PREMIUM.
Employee/Retiree Signature
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Employee Name - Print
Date
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EMPLOYEEPRE-65 RETIREE ACKNOWLEDGEMENT OF THE REQUIREMENTS FOR WELLNESS (Columbus Consolidated Government)

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Completed 22 January 2021

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