Complete Health Improvement Program (CHIP) Fill out the following attached documents* and either email to wellnesscoordinator@bhsi.com OR Fax to: 502.254.6090 Program application Participant agreement Payroll deduction form Lifestyle survey Biometric form** *Paperwork must be completed and returned by the Friday following orientation. **Biometrics must be completed and form submitted by the Friday following orientation. 1
Complete Health Improvement Program (CHIP) Application The Complete Health Improvement Program (CHIP) is an intensive lifestyle change program focused around whole food choices. Participants must be motivated and committed to making the necessary changes in order to impact their health. Once your application has been reviewed, you will be notified of your acceptance by the program facilitator. Section I Contact Information Name Employee ID: Work Location (Which Hospital/City): Home Address City/State Zip Code Home Phone # Work Phone # Cell # Work Email Address Home Email Address Indicate your preferred method of contact: Email: Home Work Phone: Home Work Cell Indicate if you are: Baptist Health employee OR Community member Section II Vital Statistics Date of Birth / / Current Height Ft. In. Current Weight lbs. Goal Weight lbs. Section III Motivation and Confidence On a scale of 0-10, how motivated are you to make significant life changes to improve your health? Not ready at all No opinion Extremely motivated 0 1 2 3 4 5 6 7 8 9 10 On a scale of 0-10, how confident are you in your ability to make significant life changes to improve your health? Not confident at all No opinion Extremely confident 0 1 2 3 4 5 6 7 8 9 10 2
Please tell us why you want to participate in the program: Section IV Medical Information Current/chronic medical conditions being treated: 1. 5. 2. 6. 3. 7. 4. 8. Please list all medications: 1. 5. 2. 6. 3. 7. 4. 8. Please sign and date below. Your signature represents that you have read, understand, and agree to the program requirements and if your application is accepted, you will be committed to the CHIP program. Signature Print name Date 3
COMPLETE HEALTH IMPROVEMENT PROGRAM (CHIP) PARTICIPANT AGREEMENT The Baptist Health CHIP Program is an intense lifestyle education course which encourages a positive outlook on life while helping participants make lifestyle changes in regard to their diet and exercise. I understand that I may expect some physical changes such as reduction in elevated blood sugar levels, reduction in elevated blood pressure, improved total cholesterol ratio, loss of weight and possible reduction in chronic disease medications. I understand that I am participating in the Complete Health Improvement Program (CHIP) of my own free will. I accept full responsibility for informing my physician of my participation in the CHIP program, my test results and any medical problems I experience while participating in the program. I will consult with my physician before making any changes in my medications. To the best of my knowledge, I have no physical or medical conditions that would be adversely affected by participating in the CHIP program. I have carefully read this document and I have had an opportunity to ask questions about the CHIP program and possible risks. My questions have been answered to my satisfaction. I also understand that I am free to ask my questions pertaining to the CHIP program at any time. I have read the CHIP material and have an understanding of the CHIP 18-session program and related commitments. I agree to the following expectations. 1. 80% on-time participation to remain in program a. Watch assigned videos and complete the coursework and the associated quiz prior to class b. Must have access to a computer for virtual learning and a telephone for virtual class/support calls c. Attend at least 15 of the 18 virtual classes/support calls attendance is not just for you, but for the group i. Cannot miss 2 classes in a row d. Complete 4 biometric and Health Risk Assessments i. Before class start date ii. Within 1 week of week 10 completion iii. Within 2 weeks of course completion iv. One year after program completion 2. Baptist Health has paid for my participation for the 18 session program. If I am not compliant with any of the above expectations or voluntarily leave the program at any time, I will be responsible to pay back 50% of the fees which will be $300. Please sign and date below. Your signature represents that you have read, understand, and agree to the program requirements and if your application is accepted, you will be committed to the CHIP program. Signature Print name Date Baptist Health Employer Solutions wellnesscoordinator@bhsi.com 4
Payroll Deduction Authorization Employee Name Employee # Facility This deduction will go to: (please check one) Baptist Health Employer Solutions If the participant in the CHIP program drops out of the program voluntarily or is asked to leave due to non-compliance with program requirements, the below amount will be deducted from their paycheck. Amount to deduct: $300.00 By signing below, I authorize Baptist Health to deduct the above listed from my paycheck. In the event I should cease to be an employee of Baptist Health, I understand that I am liable for any balance remaining and that amount will be deducted from my last regular pay. Employee Printed Name Employee Signature 5
LIFESTYLE EVALUATION Please Print Carefully Last Name First Name Middle Initial Today s Date Street Address City ZIP Daytime phone# Evening phone# Physician Did you eat or drink anything (but water) during the last 10 hours? q Yes q No Occupation: AGE: q Male q Female MARITAL STATUS: q Single q Married q Divorced q Widowed One or both parents died before age 60: of Heart Disease? q Yes q No of Diabetes? q Yes q No Check (X) if you have ever been told by a physician that you have any of the following: q Angina (yr? ) q Abnormal EKG (last 3 yrs) q Gallbladder disease q Osteoporosis q Heart attack (yr? ) q Irregular heartbeats q Gout q Osteoarthritis q Angioplasty (yr? ) q Stroke (yr? ) q Kidney disease q Rheumatoid arthritis q Bypass (yr? ) q High blood pressure: / q Diabetes q Overweight q Heart failure (yr? ) q High cholesterol q Ulcers q Bronchitis/Emphysema q Blood clotting problem q High triglycerides q Thyroid disorder q Cancer: Type List all Medications and Supplements you are presently taking on separate Medication Form. q I take none Please fill in the number of servings you eat or drink WEEKLY. If you don t use, then mark 0. Fill in every space, please. Meat or Shellfish Fowl or Fish Whole Milk or 2% Cottage Cheese Butter or Cream Cheese Sour Cream Ice Cream/Ice Milk Yogurt Liver/Organ meats Sausage/Hotdogs Eggs Fried Foods Salty Snacks Salad Dressings Mayonnaise Margarine Gravies Soymeat/Gluten Soy Milk Water Alcohol Coffee/Tea Soft Drinks Candy or Sugar Sugary Desserts Honey or Syrups Jam/Jelly/Custard REST and STRESS q Evening is biggest meal q Eat little or no breakfast q 6 hours or less sleep/night q Sleep restlessly q Suffer insomnia q Work hrs/week q Very few vacations q Feel under pressure q Eat too fast q Easily emotionally upset q Feel muscular tension q Eat between meals q Feel fearful or depressed EXERCISE (beyond everyday occupation) q None q Mild 2-3 days/week q Moderate 3-5 days/week q Vigorous 4-6 days/week BREATHING q Non-smoker q Ex-smoker (yr? ) q Smoker: Years smoked: Daily # of cigarettes: How often tried to quit: q Live with heavy smoker q Asthma, hay fever q Cough up phlegm or cigarette tar FOR OFFICE USE ONLY Height Wt Frame: q Small q Medium q Large Ideal weight Blood pressure / mmhg Pulse per minute RESULTS of blood test Glucose, Fasting Total Cholesterol LDL Cholesterol HDL Cholesterol Triglycerides Cholesterol ratio RECOMMENDATION TO IMPROVE YOUR HEALTH BASED ON TESTS AND HEALTH HISTORY ABOVE RECOMMENDED PROGRAM q Weight Management q Stress Management q Stop Smoking q Increase daily water to 8-10 glasses q Lose/Gain weight q Avoid cholesterol intake (meats, sausages, q Low Cholesterol Meal management q Low Salt Cookery q Exercise/Walking Program fowl, fish, egg yolks, liver, ice cream, cheese) q Increase aerobic/walking exercise CHOLESTEROL q Ideal q Elevated LDL q Ideal q Elevated q Substitute fruits, vegetables, potatoes for q High q Very High q High q Very High processed and refined foods q Dangerously High q Dangerously High q Increase whole grains products (breads, TRIGLYCERIDES hot cereals, brown rice, etc.) q Ideal q Elevated q Reduce or eliminate salt. q High q Dangerous q Reduce all dietary fat q Reduce refined sugar q Stop smoking q Reduce/Eliminate caffeine q Increase rest and relaxation q Make breakfast biggest meal q See your physician
Baptist Express Care Partner Clinics The following Baptist Express Care Clinics are available in your region. As participants in the Baptist Health program, you may choose to visit one of these clinics to have your biometric screening performed. Please take this Partner Clinic Kit to your local Baptist Express Care location for your health screening. Baptist Express Care Locations Located within select Walmart Super Centers Louisville Address Phone Number Louisville Hillview 11901 Standiford Plaza Drive, 40229 502-969-0526 La Grange 1015 New Moody Lane, 40031 502-991-0589 Lexington Address Phone Number Lexington Hamburg 2350 Grey Lag Way, 40509 859-263-3822 Lexington North Park 500 West New Circle Road, 40511 859-967-0964 Bluegrass Region Address Phone Number Nicholasville 1024 North Main Street, 40356 859-241-2148 Danville 100 Walton Avenue, 40422 859-236-4224 Somerset 177 Washington Drive, 42503 606-678-2880 Winchester 1859 ByPass Road, 40391 859-355-1882 Paris 305 Letton Drive, 40361 859-522-0001 Berea 120 Jill Drive, 40403 859-985-7195 Southeastern Region Address Phone Number Corbin 60 South Stewart Road, 40701 606-528-9770 Williamsburg 589 West Highway 92, 40769 606-549-5154 Paducah Address Phone Number Paducah Hinkleville 5130 Hinkleville Road, 42001 270-450-1191 Paducah Southside 3220 Irvin Cobb Drive, 42003 270-450-1240 Hanson 420 Factory Outlet Rd, 42431 270-322-5033 Hopkinsville 300 Clinic Drive, 42240 270-707-4262 Rev 12/2016 MDS
PARTICIPANT INSTRUCTIONS 1) Your biometric screening will be performed by a Baptist Express Care Clinic. While some clinics perform screens on a walk-in basis, it is important that you contact the selected clinic to determine if an appointment is required. 2) Go to a Baptist Express Care Clinic for Health Assessment / Screening and complete the consent form. Please complete the consent form given to you at the Baptist Express Care and provide all the requested information, as this will allow Baptist Health Employer Solutions to ensure that you receive your lab results. Also, please remember to sign and date the consent form in the space provided. Preparations for your exam: Fast from food starting 8 12 hours before your screen time (you may drink only water, and one 8 oz. cup of black coffee is allowed) Drink plenty of water the night before or the morning of the screening as it helps with the hydration. Limit your alcohol intake 24 hours before your screening Take all of your prescribed medication as directed by your physician Refrain from smoking 1 hour before your screening (as it may affect your blood pressure) Please return the completed Consent form to Baptist Health Employer Solutions using one of the following methods: MAIL: Baptist Health Employer Solutions RE: Program Name (i.e. Healthier You, Be Healthy, etc.) 139 S. English Station Rd. Suite 200 Louisville KY 40245 ATTN: Bonnie Gifford FAX: (502) 254-6090 (Re: Program Name/ ATTN: Bonnie Gifford) SECURE E-MAIL: wellnesscoordinator@bhsi.com (Subject: Program Name) If you have any questions, please do not hesitate to contact Bonnie Gifford via email at bonnie.gifford@bhsi.com or by phone at (502)896-7397. Rev 12/2016 MDS
Program: Healthier You Be Healthy CHIP DPP Screening: Initial Mid Program (when applicable) End of Program Consent for Release for Wellness Assessment/Screening This Personal Health Screening/Assessment is intended to help you understand health risks you may face and offer suggestions on how best to minimize or eliminate these risks. The results will be reviewed by employees of Baptist Health Employer Solutions. Generally, the information you provide: will be kept strictly confidential will not be shared with your insurance carrier or health plan, and when providing information to the employer, will not identify any single individual and will only be presented to represent the workforce as a whole However, if your employer s health plan offers an incentive program which includes participation in biometric screenings, your participation may be shared with your insurance carrier or health plan, as applicable. We may share your information with vendors that perform certain health or wellness services for your employer or health plan or who assist us in performing our services. Your results from the biometric screening form may qualify you for certain condition management programs. By completing this voluntary biometric screening form, you agree you may be contacted if you meet certain eligibility criteria for condition management programs. Your participation in any condition management program(s) is strictly voluntary. This biometric screening is not intended to replace or contradict any advice provided to you by your physicians. You understand that the results from the biometric screening are preliminary and do not constitute a diagnosis. The responsibility of initiating any follow-up about the results of your biometric screening and to obtain any medical treatment or consultation with a physician is yours alone. By completing the biometric screening and signing the biometric screening form, you consent to all elements of the biometric process, including any blood draws. You agree to release and hold harmless all organizations associated with the biometric screening, their affiliates, directors, officers, employees, successors and assigns from any and all liabilities arising from or in any way connected with this biometric screening. Please provide all information requested below: Full Legal Name (print): (last) (first) (MI) Age: Date of Birth: Gender: M / F Employee ID # Las 4 of SSN: / / / Email: Preferred Phone: Address: City: ST: Zip: Please answer the following questions: 1. Are you a diabetic? Y / N 2. Do you have a primary care doctor Y / N Doctor Name: 3. Do you use tobacco? Y / N (Tobacco use means any tobacco product in the previous 6 months) 4. Please circle any that you are currently being treated for: High Blood Pressure Diabetes High Cholesterol Asthma Signature Clinic Staff Use Only RESULTS: Fasting Non-Fasting Height (total inches) Weight (lbs) BMI Abdominal Circumference (at navel, round down to nearest quarter inch) Blood Pressure Total Cholesterol (TC) TRIG HDL LDL TC/HDL ratio Glucose Rev 7/29/16 MBC Baptist Express Care location: Staff Initials