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Notice of Privacy Practices
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
I voluntarily consent to having the health screening tests offered at my workplace.
I understand that my participation in this Biometric Testing program is voluntary. I understand that my individually Identifiable Biometric Testing data will not be shared with my employer. CHA recognizes the importance of safeguarding Personal Health Information (PHI) completely and will take reasonable steps to protect such PHI from any unauthorized access or use.
I, the undersigned, hereby consent to the collection of data from one or all of the following tests including: blood pressure, body composition analysis, and a finger stick blood sample for the purpose of measuring my Total Cholesterol, HDL Cholesterol, and Glucose. I hereby release Clinical Health Appraisals, Inc. (CHA) and any of their affiliates, directors, officers, employees, successors and assigns, from any liability arising from or in any way connected with my participation in any of these tests or from the use of data derived there from.
I understand that: The data derived from these test(s) are considered to be preliminary; they are screening assessments only. They do not constitute any diagnosis and are for health information purposes only. The responsibility for initiating a follow-up examination to confirm the results of this screening and obtain professional medical assistance is mine alone, and not that of any organization(s) associated with this screening.
