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.