Biometric Screening Consent Form

University of Virginia Health Plan
Biometric Screening
Consent Form

     The biometric screening, together with Aetna's health assessment, is designed to provide feedback that will help you evaluate your current lifestyle, identify health risks, and decide where and how to make improvements. It does not provide a diagnosis of medical problems. A follow-up visit with your primary care physician to confirm the results of the screening and obtain further medical help is highly recommended.

     Your personally identifiable information and screening results will be shared only with health improvement programs offered to University of Virginia Health Plan participants including but not limited to the smoking cessation and disease management programs. You may be contacted by program counselors to assist you in obtaining care if your assessment results point to this as an appropriate action.

     Your individual screening results will not be shared with your employer. The University of Virginia Health Plan will receive only de-identified, aggregated data reports regarding the health of its covered employees.

     You have the right to revoke your consent for screening results to be shared with the health improvement programs, except to the extent that results have been released prior to delivery of your revocation to the University of Virginia Health Plan. This consent expires two years after the date of the biometric screening. If you revoke your consent, you will not be eligible for incentive payments. 

     Your completion and submission of the information below indicates that you voluntarily agree to all of the preceding provisions.