By clicking Accept Terms and completing my assessment, I confirm that:

A. I am voluntarily participating in this Health Power Assessment (HPA) to: 1) Help me and my doctor regularly assess key measures of my health, safety, well-being, related opportunities to improve &/or my progress toward such goals; 2) Detect potential health risks and problems earlier for better follow-up and outcomes; 3) Save personal expenses;  4) Earn (or meet requirements toward) one or more incentives;  AND/OR 5)  Meet one or more requirements of my health benefit plan(s) to obtain/retain the related financial and/or other benefits of doing so.

B. I authorize: 1) HPNWorldWide (HPN) to provide me my results; and 2) HPN and other groups to provide related support as described in C and D below;

C. This HPA: 1) DOES NOT attempt to diagnose or recommend medical treatment;  2) WILL include one or more personal reports (printed and/or online) provided to (and accessible by) me and to share with my doctor; and 3) MAY include follow-up calls and other support (as available) from a nurse, health coach, physician and/or other qualified health professionals for appropriate follow-up, my better health and/or health care; and

D. I have read, understand, agree with and accept: 1) A, B & C above; 2) The HPA Terms & Privacy Notice (below) which informs me of the risks of this HPA, how my personal health information will be used and protected including being in compliance with the Health Information Portability & Accountability Act (HIPAA) and of my related rights; 3) That any attempts by me to modify or amend this form will not change the original terms or in any way be binding upon my* employer or health plan (or my spouse's employer or health plan) sponsoring this HPA, HPN and all other involved HIPAA Business Associates;  and 4) My information about me (address, phone, other personal identifiers) and my answers to the HPA questions are accurate.

HPA Terms & Privacy Notice

This notice discloses the risks of the HPA and how we and you can protect against those risks, how health information about you will be protected and how it may be used, your related rights and your responsibilities.  HPN and other involved HIPAA business associates share the commitment to serve you and all other customers with professionalism and care in the delivery of services (described below and above in sections A, B, C and D) that: 1) Are safe; 2) Safeguard the privacy of all Protected Health Information (PHI); and 3) Are in abidance with the Health Insurance Portability and Accountability Act (HIPAA), other relevant laws and regulations, public health and clinical guidelines. PHI is defined as your medical, health and individually identifiable information, such as your name, address, telephone number or social security number (in any format) obtained and used in the delivery of HPA-related services described herein.

I. Risks and Protecting Against Them - It Takes Everyone

The risks associated with taking the HPA (online, by paper or computer) can include the possibility of:  questions not being answered or entered accurately, data not sent or received accurately (via the internet, mail or other means) and related risks of receiving information and follow-up based on such data or the absence of it and/or not following up with your usual source of health care (e.g. doctor - see II-B, below) as advised in your HPA report(s).  HPN minimizes potential data capture and transmission risks through quality controls in HPA website, internet and data systems, technologies, staff and processes to protect your PHI and data integrity.  It is also important for YOU to:

A. Answer all questions accurately and verify accuracy before moving from one question or page to the next.

B. Not skip any questions.

C. Follow-up with your doctor (or other appropriate qualified sources of support) as suggested in your report(s).

II. Your Responsibilities

A. This HPA includes asking you questions that are related to your current and future health. As such, it is important that you answer these accurately and completely (not leaving any questions unanswered) in order for you to obtain a personal report that is MOST accurate, credible, meaningful and helpful to you;

B. It is your responsibility to follow-up with your usual source of health care (e.g., doctor, nurse practitioner, physician assistant) and share these screening results with them on the next visit, or earlier, if your report suggests doing so; and

C. Your honesty, completeness and follow-up is in addition to your responsibilities specified above in section I (ABC) and helping to protect your own privacy by sharing your PHI and personal login only with those you trust.

III. Protection of Your PHI

We will protect your PHI by maintaining and enforcing policies and procedures that comply with all known HIPAA regulations including, but not limited to:

A. Restricting usage and disclosure or your PHI to the areas described in section IV (below);

B. Obtaining your consent before releasing your PHI for any purpose other than those purposes identified in section IV (below); and

C. In any of these authorized instances, limiting the use and disclosure to the minimum information necessary to perform the required task.

IV. Legal, Protected Uses of Your PHI

During the course of serving you we may be required to use and share your PHI with other health care providers, legal authorities and HIPAA Business Associates of your employer and/or health plan (also abiding by HIPAA) involved in routine benefit plan operations, the delivery of health care and support resources to improve the health, well-being, safety and health care of you and others. The following are examples of how your PHI may be used for such purposes:

A. We may use your PHI to contact you about your screening results or to send you reminder(s) about a screening and/or available support resources.

B. We may share your PHI with your health care provider(s), health benefit plan and appropriate HIPAA Business Associates specializing in health care counseling, health coaching, risk/disease/condition and other outreach support services (sponsored by your employer or health plan) to provide appropriate information and support.

C. IV-A&B (above) mean that you may receive one or more phone calls from a physician, nurse, health education specialist, registered dietician, exercise physiologist or other qualified health professional, and reminders and other support resources by mail, online (the internet) and other means to assist you with personal actions that may be needed to follow-up on specific screening results, improve your health and/or health care.

D. We may disclose your PHI to your health benefit plan or any other health care payer that you or your employer identifies for the purposes of receiving and/or making payments pursuant to the health plan and/or incentive plan.

E. We may use your PHI for research to improve the health support services to you and others, outcome evaluation and best practices in health care, public health and routine health plan operations.

F. We may disclose your PHI to Emergency Medical Personnel in the event of a medical emergency.

G. We will disclose your PHI to the appropriate public health and/or other legal authorities, as required by law and to the extent necessary to avert serious and imminent threat to your health or safety or the health or safety of others.

H. We may include your results (anonymously) in group or aggregate administrative reports where only screening summary results of the entire group are reported (with no personal identifiers - e.g., no names).

V. Your Rights:

A. You have the right to inspect and review your PHI online at the website indicated on page 2.1 of your health power assessment report. This free annual 24/7 access is renewed each year that you participate in this wellness screening.

B. You also have a right to request re-prints or photocopies of your PHI and related reports by obtaining a form from the Privacy Officer of HPN (see IV below for contact information). This and other requests below must be made in writing. Please note that there is a minimum charge of $15 per report plus shipping charges to locate, print and send you your PHI. However, if you have access to the internet and your results online, you can avoid any such charge. Here's how: Login to the website listed on page 2.1 of your health power assessment report and view and/or print any of the reports yourself.

C. You have the right to request and receive a list of instances in which we disclosed your PHI.

D. You have the right to request that we place additional restrictions on our use or disclosure of your PHI. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement.

E. You also have the right to agree to terminate a previously submitted restriction.

F. You have the right to request that we amend your PHI. Your written request must explain why the information should be amended. If we accept your request to amend your PHI, we will do so and make reasonable efforts to inform appropriate others of our amendment, and will include our changes in any future authorized disclosures of your PHI. We may deny your request in instances where we did not create the information or where the information is complete and accurate. If we deny your request, we will provide you with a written explanation.

G. You have the right to register a complaint. If you believe we have violated your privacy rights you may file a complaint with us by submitting your complaint in writing to the Privacy Officer of HPN. You may also submit a written complaint to the U.S. Department of Health and Human Services (HHS). We will provide you with the address to file your complaint with the HHS upon request.

VI. Contact Information

If you have a request, complaint or questions regarding how HPN handles your PHI you may contact us by:

A. E-mailing us at:

B. Calling us at: 630.941.9030

C. Writing to us at: HPN WorldWide, Attention: Privacy Officer 119 W. Vallette, Elmhurst, IL 60126

VII. Effective Date & Future Updates

This Notice takes effect on December 18, 2008. We reserve the right to change and update this notice (mainly to reflect changes in laws and regulations as they occur) and any such updated notices will apply to PHI we already may have and PHI collected thereafter. The most current version of this notice is provided at the time of each HPA and is available on this website in this location - the web site specified on page 2.1 of your health power assessment report.