Wellness Incentive Program

Current screening year: September 1, 2022 - August 1, 2023

Employee Wellness has been working hard on revising our new wellness program for this year. Highlights for this year include a preventative care HRA credit and a new program series category. Please review the Notice Regarding Wellness Program.

The Wellness Incentive adds dollars back to your paycheck to offset healthcare cost. Both employees and spouses are eligible. $33.93 for employee/$11.30 for spouse.

Incentive Requirements

Annual Wellness Visit with your Primary Care Provider (August 2, 2022 – August 1, 2023)
- 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.

PCP Proof of Visit &
EMR Access Authorization Form

How to complete the above requirements
While the deadline is August 1, 2023, 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, 2023 (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.

How to Tell PCP Form has been submitted
PDF

Earn Reward Dollars
Employees and spouses can earn up to $400 into their Health Reimbursement Account (HRA) by participating in additional wellness activities. (Nutrition Counseling, Pathway Programs, Wellness Series Education, Wellness Challenges, etc.)

You must complete the wellness incentive by the August 1 deadline to earn your HRA dollars. Do not enter HRA credit if you are using the PCP visit for your incentive.

Rewards Activity Handout >

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

First Name:

Last Name:

Employee ID :

• Employees - Enter only your ID# without the letters
Example: 54321
• Spouses - Enter the employee's ID# followed by sp
Example: 54321sp

Date of Birth:

I am... (choose one):

A Deaconess Employee
The Spouse of a Deaconess Employee

Are you currently pregnant?:

Yes
No
N/A

Primary Care Physician:

Date of Wellness Visit:

Date of Labs:

Are you a diagnosed diabetic?:

Yes
No

If yes, and your A1C is under 7.5 – are you interested in the Free Supply Program?:

Yes
No
I wish to continue participating in the Free Supply Program

If yes, and your A1C is greater than 7.6 – are you interested in working with MTM to participate in our Free Supply Program?:

Yes
No
I wish to continue participating in the free supply program

If you indicated yes, you are interested in working with MTM, please provide your email address below:

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.

Signature: