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Tobacco Free AttestationTo attain the tobacco‐free goal, complete this form. Before filling out this form, make sure you read and understand what constitutes tobacco use as outlined below.
Employees who are not tobacco‐free can also qualify!Attend The Butt Stops Here tobacco cessation classes. To enroll or for more information call 459.2550.
Program enrollees will receive a certificate of completion. Upon completion of the program Ellis employees will be reimbursed the registration fee.
Our hope is that employees will eventually quit and sustain this healthy lifestyle choice.
Tobacco‐Free DeclarationFor purposes of this declaration, Ellis Medicine defines tobacco use as smoking cigarettes, clove cigarettes, cigars or pipes, or using chewing tobacco, smokeless tobacco, or any other form of tobacco at least once per week. Non‐tobacco users are individuals who have not used tobacco products within the last 90 days.
Description of your Healthy MEE Activity:
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Date (s) _____________________________________________________
Please explain how this helps your personal well-being:
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Healthy MEE Activity – One & TwoDocument your participation in two (2) different approved Wellness Activities.
Submit completed passport booklet to Employee Health no later than October 31, 2016.
For more information: [email protected]
Print Name __________________________________________________
Department _________________________________________________
Please mark your designation below:o I certify that I have read and understand what
constitutes tobacco use and that I am tobacco‐free!
o I certify that I have read and understand what constitutes tobacco use and have completed The Butt Stops Here smoking cessation program and have attached my original completion certificate to qualify for the tobacco‐free goal.
o I agree that if this information changes, I will notify Ellis Medicine of such change in writing.
I certify that the above information is true and correct and understand that providing false information on this form may result in a loss of medical coverage as determined by the company.
Employee Signature _________________________________________
Date __________________ | |
HEALTHY MEEHelping me be a
Submit this completed passport to Employee Health, no later than October 31, 2016.
For more information: [email protected]
Healthy MEE2016 WELLNESS PROGRAM
PASSPORT A GUIDE & OFFICIAL PASSPORTTO HELP ALL ELLIS MEDICINE EMPLOYEES ACHIEVE ANNUAL WELLNESS GOALS.
Name _______________________________________________
Department _________________________________________
Contact Number _____________________________________
Description of your Healthy MEE Activity:
______________________________________________________________
______________________________________________________________
Date (s) _____________________________________________________
Please explain how this helps your personal well-being:
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Ellis Medicine wants employees to enjoy happier, healthier and productive lives. We encourage all employees to participate in the 2016 Healthy MEE Wellness Program. Your Ellis Wellness program is committed to helping you achieve your best health. Please use this passport to track your accomplish-ments and to submit your documentation to Employee Health by October 31, 2016. Rewards for participating in the wellness program are available for ALL employees.
If you think you might be unable to meet a metric for a reward under the wellness program, you might qualify for an oppor-tunity to earn the same reward by different means. Contact [email protected] and we will work with you (and if you wish, with your doctor) to find a wellness activity with the same reward that is right for you in light of your health status.
Employees who complete ALL 6 (six) metrics listed below may qualify for a 15% premium discount on their Ellis Health Insurance Rates for 2017*. All employees regardless of participation in our health insurance may submit their completed form.
Set a Wellness Goal for 2016Example: I will work toward getting 20 minutes of exercise most days of the week.
Wellness Activities ChecklistEllis employee submits completed passport booklet to Employee Health by October 31, 2016.
For more information: [email protected]
Influenza Vaccine Health Practitioner DocumentationSubmit your Influenza Vaccine documentation to Employee Health, acceptable dates for the 2015 – 2016 Influenza Vaccine are between 08/01/15 and 06/30/16.
Preventive Physical ExamScheduling a preventive wellness examination with your physician is important to you for so many reasons. The relationship you and your physician develop is essential to your well-being and future good health.
Instructions – to be completed by your provider1. Receive a preventive physical examination from your
primary care physician, NP/PA or internist between 11/1/14 and 10/31/16. Please note an Ob/Gyn exam will not be considered as a qualifying visit towards the premium discount.
2. Have your physician sign the attestation below
3. Return this passport to the Employee Health office by 10/31/16.
Examples of qualifying Healthy MEE Wellness Activities Healthy MEE onsite fitness class such as Yoga, Zumba or Tabata (minimum of 4 classes)
Ellis Medicine sponsored or other physical activity race or event – Examples: Relay for Life, Corporate Challenge, March of Dimes Walk, American Heart Walk, Cardiac Classic, Sche-nectady Gazette Holiday Parade
Completed Health Care Proxy – all forms available on the employee health intranet
Fitness Journal or Tracker demonstrating a minimum of 10 instances of activity – Example: paper log or print out from your favorite fitness
app. gym membership activity log
Participation in a team sport or league.
Consultation with dietitian
Validated weight management program participation – – Examples: Weight Watchers, Jenny Craig
Healthy MEE Wellness Fair
Proof of participation in other nutrition class or training
Proof of participation in other stress management activity
Attend a Capital EAP Workshop
Proof of participation in other Wellness/Health Management Programming
– Examples: Diabetes Prevention program, Ellis Asthma Care, Tobacco Cessation Classes, Bariatric Program, Complete the Ellis Woman’s Cardiac Risk Assessment
Donate blood at an Ellis Medicine Blood Drive
Complete MVP Wellness Tools and Activities program on-line
Participate in Integrated Therapy or Massage Therapy
Participate in a Know Your Numbers Screening
Participate in the MVP Care Advantage Program at 888.687.6367
Completing the Personal Health AssessmentAll employees regardless of participation in our health insurance are eligible to take the Personal Health Assessment (PHA). Go to www.mvphealthcare.com
MVP Member Instructions: Enter your username and password on the left side of screen and click log in
Click the icon
Take the Personal Health Assessment
Non‐MVP Member Instructions: If you do not have a username and password for the MVP website, click create an account now under choice two to register, using Ellis Medicine’s MVP Group ID: 211010
If you’re unable to retrieve an existing username and/or password online, contact MVP ESupport at 888.656.5695
Health Practitioner or Office Stamp
Signing this document serves as proof that:
Name: _____________________________________________
was seen for a preventive physical examination on: ________________________
Provider’s Signature: _________________________________________
Office Stamp:
____________________________________________________
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Be sure to PRINT the completion certificate and attach to this passport.
REQUIRED METRIC Must be done between Due Date Available Points Date Done
1 Influenza Vaccine 8/1/15 to 6/30/16 6/30/16 20 Receive the 2015‐2016 influenza vaccine and provide proof of immunization to Ellis Works Employee Health.
2 Preventive Physical Exam 11/1/14 to 10/31/16 10/31/16 20 Receive a preventive exam from your primary care physician (Ob/Gyn exam will not be accepted).
3 PHA‐Personal Health Assessment 11/1/15 to 10/31/16 10/31/16 20 Log in or register at mvphealthcare.com. All employees have access to the PHA and Wellness Tools.
4 TOBACCO FREE ATTESTATION 11/1/15 to 10/31/16 10/31/16 20
5 Healthy MEE Activity One 11/1/15 to 10/31/16 10/31/16 10 Submit your completed Wellness activity entry form
6 Healthy MEE Activity Two 11/1/15 to 10/31/16 10/31/16 10 Submit your completed Wellness activity entry forms.
100 points must be earned in order to complete the 2016 Healthy MEE Wellness Program
My 2016 Personal Well-being Goal is:
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