Diabetes Prevention Program Registration Form

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Please fill out as completely as possible. ALL personal information is strictly confidential. PLEASE HIT SUBMIT WHEN FINISHED. Thank You!

Name *

Email *

Phone Number *

Date of Birth (you must be at least 18 to participate) *

YYYY

Home Address (address, city, state, and zip code) *

Race (check all that apply) *

American Indian or Alaska native

Asian

Black or African American

Native Hawaiian other Pacific Islander

White

Other:

Required

Ethnicity *

Hispanic

Non-Hispanic

How did you hear about the program? *

Doctor

Friend/Family Member

Web Search

Media

Other:

Do you have a previous diagnosis of type 1 or type 2 Diabetes? *

Yes

Have you been diagnosed with end-stage renal disease? *

Yes

Height (in inches) *

Weight (in lbs) *

Please check any of the following blood tests that you have had in the past 6 months.

Hemoglobin A1c test

Fasting Blood Glucose test

Random Blood Glucose test

None

Clear selection

Were any of the above tests abnormal or "high? If so which test(s) and what were the date(s) and result(s)?

Name and contact of Doctor who ordered the test(s)?

Have you had a previous diagnosis of gestational diabetes?

Yes

Clear selection

What is your motivation to participate in a Diabetes Prevention Program? *

Health care Professional

Physician

Pre-diabetes risk test

Someone at community -based organization (include faith -based organization)

Family or friends

Employer or employee plan

Other:

(PLEASE READ AND CHECK THE BOX BELOW THIS AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION, THEN HIT "SUBMIT." AVOH is a partner with Welld Health for electronic health record management.) -------------------------I request that my health information be released by Welld Health, LLC as set forth on this form, in accordance with the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”). I further authorize Welld Health, LLC to use the health information listed below for the purposes listed below or to disclose the information listed below to the agencies listed below. This health information shall be disclosed to or exchanged with and used by all individuals and agencies who I accept as “Connected Parties” on the Welld Website. These “Connected Parties” may include healthcare providers, fitness clubs and their personnel, and other Welld members who I accept as “Connected Parties.” My employer may be a “Connected Party,” but will not be entitled to access my health information. No individual or agency will become a “Connected Party” unless I affirmatively accept the connection on the Welld Website. The health information that may be used and/or disclosed by Welld Health, LLC includes: (a) Diagnosis,(b) Discharge/Transition, (c) Assessments, (d) Summary, (e) Social History, and (f) Treatment Plan. Purpose of use and/or disclosure: (a) Assessment, (b) Follow-up, and/or (c) On-going.As the person signing this Authorization, I understand that I am giving permission for Welld Health, LLC to release or to obtain and use confidential health information. No threat or other coercive measures have induced me to sign this form. I may refuse to sign this authorization, but I understand that if I refuse to sign, I will not be able to use the Welld Service. A copy of this Authorization and a notation concerning the persons or agencies to whom disclosure was made shall be included with my health records. I understand that I am entitled to a copy of this Authorization. I also understand that the information disclosed may be subject to re-disclosure by the recipient and may no longer be protected by state or federal law. I understand and consent to the use of a copy of this form as equivalent to the original. I understand that I may revoke this Authorization at any time, but not retroactive to information already released in accordance with this Authorization. I will notify Welld Health, LLC in writing of my desire to revoke this Authorization; my revocation is not effective until (a) delivered in writing (which must identify my name and the e-mail address associated with my Welld account) to the person in possession of the medical records, or (b) I close my Welld account through the Welld website. In addition, I understand that I may sever a connection with a “Connected Party” at any time. If I sever a connection, the individual or agency whose connection I severed will no longer be able to access my health information, but it will not affect information already accessed or used by the individual or agency in accordance with this Authorization. Unless I revoke this Authorization earlier, this Authorization will expire when I delete my Welld/ AVOH account.

I certify that I have read this form and agree to continue the program.

Submit

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