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2011 – 2012 PARTICIPATION AGREEMENT The STEPS program was specifically designed to work with you and your primary care provider to help manage your health and medication. In order to ensure you receive the maximum benefit from the program, it is important that you understand and agree to the patient responsibilities outlined below. As a patient participating in the STEPS program (please initial each box to indicate your agreement):

I acknowledge that the educator has explained the program to me and answered my questions in sufficient detail to help me understand the details of the program. I agree to allow information about my medical condition and care to be collected and added to other patient data for reporting and analysis purposes. I understand that no personal information that can identify me will ever be shared or reported. I understand that my participation in this program is voluntary. I will provide complete and accurate information when requested by the educator as it pertains to my health and understand that it is important to discuss my care with all my other health care providers. I agree that pictures of me can be used to promote and market the STEPS program. I understand that if I elect to connect with STEPS via Facebook that Facebook is a public social network and information I post will not be private. Each participant is responsible for setting individual privacy

settings on Facebook and the Facebook Policy Agreement applies to all information, pictures, applications, etc used on Facebook.

CONSENT FOR RELEASE OF MEDICAL INFORMATION ▶ I understand that the educator may need to discuss my care with my physician, other health care providers and my insurance company if required to obtain reimbursement. I do hereby grant permission for the STEPS educator to request certain medical/health information from my other healthcare provider(s). This information will be shared with my educator confidentially and specifically for my care.

I WISH TO ENROLL IN THE FOLLOWING PROGRAMS:

STEPS Monthly Management Plan

FREE

STEPS Fitness Center

FREE LISD Employees

STEPS FFF – Fabulous Flab Fighters

$15.00 FEE for materials

STEPS Biggest Loser Contest

$25.00 September 16 – December 9, 2011

STEPS No Excuses Training Program

$50.00 per month

STEPS FREEDOM From Smoking Program

$25.00 – Will be returned if smoke free at 3 months

$10.00 a month others

By signing my name below, I acknowledge receiving a copy of this document and agree to the terms of participation as outlined above. I understand that I may discontinue my participation in the STEPS Program at any time by sending a written notice to the above named provider. I also understand that any release of medical information prior to my revocation shall not constitute a breach of my rights to confidentiality.

Date

Print Employee Name

Employee Signature

Employee Date of Birth

Campus/Department

Address

Physician/Healthcare Provider

City, Sate, Zip Code

STEPS enrollment form  

Enrollment form for STEPS program

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