Newtopia Wellness Program Authorization to Use and Disclose Health Information
By signing this Authorization below, I authorize the following:
- I authorize Newtopia to share the information described below with my employer, my employer’s Wellness Vendor, and my health plan (collectively, the “Recipients”) for the Recipients to administer, evaluate, and pay for the Newtopia wellness and/or pilot program (the “Newtopia Program”) and provide me with incentive or rewards programs, where offered, in connection with my participation in the Newtopia Program. Specifically, the information to be shared with the Recipients includes:
- My name and demographic information, including my ID number, date of birth, and contact information.
- Information regarding my participation in the Newtopia Program, including the number of times that I:
- Log food manually, onthe online portal, or the web app;
- Log activity or usetheactivity tracking device;
- Participate in coaching or CCM sessions(includingany electronic coaching or CCM communication);
- Complete a “Newtopia Challenge”; and
- Track weight manually or via a tracking device such as a Bluetooth scale.
- I understand that:
- This Authorization will expire as of the date on which I am no longer participating in the Newtopia Program, or no longer covered under my employer’s health benefit plan.
- I can revoke this Authorization at any time by writing to Newtopia at firstname.lastname@example.org, so that future sharing or use is not permitted. I understand that my revocation will not be effective for information already used and disclosed in reliance on my authorization.
- I understand that once my information has been disclosed, federal privacy laws may no longer apply or protect the information from further disclosure.
- I understand that my treatment, payment for treatment, health insurance enrollment or eligibility for benefits will not be affected if I refuse to sign this Authorization, but that I may not be able to participate in the Newtopia program or receive my employer’s rewards or incentives if I do not sign.
- I may obtain a copy of this Authorization to keep for my records.