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Wellness Incentive Program

Current screening year:  July 1, 2023 - August 1, 2024

The Wellness Incentive adds dollars back to your paycheck to offset healthcare cost. Both employees and spouses are eligible.

Incentive Requirements

  • Annual Wellness Visit with your Primary Care Provider (July 1, 2023 – August 1, 2024)
    • Must contain height, weight, blood pressure, cholesterol, and glucose for all; and A1C for those who have diabetes
    • If you are currently pregnant, labs are not required, but all other items would need to be obtained by the Primary Care Provider.
    • OB visits with or without lab work does not count.
PCP Proof of Visit &
EMR Access Authorization Form

How to complete the above requirements
While the deadline is August 1, 2024, it is recommended to complete the incentive requirements earlier in the year to allow for time to complete MyWellness Portal activities and earn HRA dollars

  • Deadline:  August 1st, 2024 (includes PCP visit submission and all HRA activities)

  • You must complete the PCP visit to earn HRA
  • ​If you are benefits eligible after April 2nd you will be grandfathered in and receive the wellness incentive for you and your spouse (if elected on the insurance). Reference the Grandfathered Wellness Flowchart for more information. 

Authorization to Obtain EMR for Annual Wellness Exam with PCP for Wellness Incentive

• Employees - Enter only your ID# without the letters
   Example: 54321
• Spouses - Enter the employee's ID# followed by sp
   Example: 54321sp
I am... (choose one):

Are you currently pregnant?:

A confirmation email will be sent to the above address when the form is submitted. We will reach out to this email for additional information if needed.

I hereby authorize Deaconess Clinic Wellness Solutions to obtain information from my medical records maintained by Deaconess to be used for my wellness screening.

  • Information to be obtained from my annual exam includes: height, weight, blood pressure, total cholesterol, LDL, HDL, triglycerides, and glucose for all; and A1C for those who have diabetes.
  • This authorization will expire 1 year from the day authorization is signed. I understand I have the right to withhold this information and can use other wellness incentive options to fulfill the incentive requirements.
  • I understand that once the information is disclosed, it may be redisclosed and no longer subject to the privacy provisions of HIPAA.
  • I may choose to revoke this authorization at any time by providing a written letter to the wellness manager.

I authorize Deaconess Clinic Wellness Solutions to release my name to my place of employment for the purpose of confirming participation, and, if required, whether care plan objectives were met or number of risk factors in the wellness program.

The information will be stored in a system called Applied Health Analytics which will have restricted access to secure protected information. The information you provide will be kept strictly confidential and will not be shared with your insurance carrier. Your employer will not be provided any other personal information about you except as aggregate data that does not identify any single individual. I understand that I can refuse or revoke this authorization; however, if I do so, I will not qualify for the incentive, should my company offer one.

I understand that revocation will not apply in those instances specified in the applicable Notice of Privacy Practices. If I revoke this authorization I must do so by sending my request in writing to Deaconess Clinic Wellness Solutions. I understand that the material released as a result of this authorization may be subject to re-disclosure and no longer protected by the laws applying to medical information release. This authorization will expire 60 days after date signed unless otherwise specified as follows: 1 year.

After clicking the submit button below, please make sure there are no error messages and wait for the confirmation page to load to ensure your submission has been received.

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