Please allow 7 business days for your application to be processed. Once it is processed you will receive an email response. If you have questions after the 7 days please call 1-866-688-7493.

Application Date: MM-DD-YYYY  
First Name: *  
Last Name: *  
Gender: *  
If you are female, are you currently pregnant?
*
Date of Birth: * MM-DD-YYYY
Current Weight:   * pounds  
Current Height: * feet  inches     
Waist Circumference:   * Inches
BMI Score Calculation:    
Do you have PEIA PPB insurance?
     *  
Have you ever participated in the PEIA Weight Management Program?
     *  
Have you ever had bariatric surgery (lap band or gastric bypass)?
     *  
If you have had bariatric surgery in the past how many years ago did you have the procedure?
 
Are you considering having bariatric surgery?
     *  
Social Security Number: *
Primary Cardholder SSN: *
Primary Cardholder PEIA ID:
*  
PEIA ID Numbers should start with 770.
Are you a medicare recipient?
Mailing Address: Street: *
City: * State: *

Zip: *
County:
Email: *    
This voluntary program uses email as the primary method of communication and a valid email address is required for participation.
For the phone numbers below please list only the numbers where you would be willing to take our calls.
Phone Number:

I wish to recieve my monthly check-in using the following method (choose one)
Monthly check-ins are a required component of the program where the member interacts with staff to discuss progress in the program.





Select your preferred location: *  

Please read and click on the I agree box at the bottom. *  
Click here to print program agreement

Weight Management Program Consent Form

Introduction: I understand that if I am eligible, I may choose to participate in services provided by the PEIA Weight Management Program. The purpose of this program is to help me achieve a healthier weight and learn to better manage my risk factors by developing a healthy lifestyle, including changing my eating and physical activity habits. This program is designed to teach these skills for use over the course of a lifetime. I understand that if I decide to participate in this program, I will be asked to complete various assessments, forms and questionnaires; keep an eating journal, have a fitness assessment and other various health screening measurements taken. In addition, I will be required to attend meetings, educational sessions, complete self-monitoring forms and comply with other participant assignments.

Potential benefits. I have been advised and understand that this is a Weight Loss Program, but that no guarantee can be made concerning the expected results from my participation in the program. I further understand that my chances of successful weight loss and maintenance depend a large extent on how much effort I put into following the techniques and strategies suggested throughout the program. I further understand that I also may experience other health benefits, including reduction in blood pressure and blood cholesterol and improvements in cardio-respiratory fitness, by changing my eating and physical activity behaviors.

Potential risks. I understand that as a part of the program, I will be encouraged to decrease my caloric intake and increase my daily physical activity. I am aware that making such changes may have certain health risks, and I hereby consent to and accept all such health risks. I have been advised and understand that I assume responsibility to obtain clearance from my physician for me to participate in this program. If I am asked, I will provide a written permission obtained as a medical clearance from my physician for me to begin this program. The written clearance is not standard for the program, but may be required upon review of my application. If I choose not to follow these recommendations, I accept complete and total responsibility for any and all consequences and forever hold harmless PEIA, its officers, directors, employees, and agents, free from any liability for any and all such consequences. I further understand and agree that in the event of a medical problem during or resulting from the program that I am completely and solely responsible, legally, financially, and in all other respects whatsoever.

Confidentiality. I further understand and agree that as a part of the program, I will go through an evaluation and assessment phase where I will be asked in interviews and via questionnaires about my current lifestyle, health matters, and issues about relevant personal matters. I understand that PEIA and all persons gathering this information will treat this information and all other information obtained throughout my participation in the Program with strict confidentiality and will not release this confidential information to anyone other than PEIA employees, business associates, and medical providers, as necessary for my care and payment of my claim without my written authorization or as required by law. I understand and agree that if I change providers my information from my earlier provider(s) will be shared with my new provider(s).

Voluntary Consent/Right to Withdraw. I hereby acknowledge and affirm that it is my sole decision to voluntarily participate in the PEIA Weight Management Program and that I may quit at any time and for any reason whatsoever.

Reasons for Involuntary Drop. I further understand and agree that I may be dropped from the PEIA Weight Management Program for cause without my consent if the program staff decides that my continuing the program would be harmful to me or to others; if I fail to comply with compliance standards or if I falsify any information regarding the program.

Healthcare Insurance Coverage Notice

Only members covered by PEIA’s Preferred Provider Benefit (PPB) plans A, B, C, and D are eligible to participate in the Weight Management Program. This is not a covered benefit for those covered under The Health Plan or Humana through PEIA. When PEIA reviews your application, your insurance coverage will be reviewed and it must be determined that you are covered by the appropriate plan at the time of your application.

However, it is the participant’s responsibility to immediately report any insurance-related changes to Weight Management Program administration by calling 1-866-688-7493, for staff to verify continued eligibility to participate in the program. If Weight Management Program services are provided to an individual who is no longer eligible, this will result in additional outof- pocket costs in the form of denied claims.

Examples of changes to report include, but are not limited to:

  • Changing from a PPB plan to The Health Plan
  • Changing from a PPB plan to Humana
  • Changing from a dependent status on one policy to the policyholder on a new policy
  • Changing from a PEIA PPB plan to a completely different insurer (i.e. Blue Cross/Blue Shield, Medicaid)
  • Change of jobs, resulting in a lapse in coverage
  • Any anticipated lapse in coverage
  • Any change resulting in receipt of a new policy number
  • Changing to or from COBRA coverage.

I certify and attest that I have read and understand all the information contained in this notice, Furthermore, I understand that failing to report any changes involving insurance coverage and/or status may result in additional out-of-pocket costs that will be my responsibility.

Physical Activity Acknowledgement

You will be engaging in various physical activities each day as part of your personalized program. A vital part of the Weight Management Program is the exercise portion of the program. PEIA assumes no responsibility for your level of fitness and/or physical ability to safely perform exercise. You should consult with your physician to determine your ability to safely participate in exercise activities. PEIA does not practice medicine and cannot examine your level of health or fitness to participate in this program, only a licensed provider can do this.

As you exercise, medical authorities recommend that you stop the activity if you notice any of the following:

  • CHESTPAIN
  • DIZZINESS/LIGHT-HEADEDNESS
  • CONFUSION
  • NAUSEA
  • COLD/CLAMMY SKIN
  • NOTICEABLE CHANGE IN HEART RHYTHM
  • SEVERE PAIN OF ANY KIND
  • SHORTNESS OF BREATH
  • SEVERE FATIGUE
  • EQUIPMENT IRREGULARITIES

Stop exercising if you experience any of the above symptoms, which could lead to a serious lifethreatening situation, or even death.

Please report any of the above symptoms to your physician, and your exercise physiologist or personal trainer.

Participant Statement. I hereby certify and attest that I have read and understand all the information contained in this communication. I hereby voluntarily consent to participate in the PEIA Weight Management Program should my application be approved.

    
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