CMC Passport to Wellness Registration

Start your wellness journey today!  The CMC Passport to Wellness program is available to CMC employees only.  Get moving by submitting the form below.   If you prefer to submit a physical copy of this registration form, please download it here and follow the instructions.

By submitting this form, you attest that you understand and agree to the following:

1. Only CMC employees are eligible to participate in this program.
2. The CMC Passport to Wellness program is optional and voluntary. I am not required to participate at any level, and my employment or status as an employee is not contingent upon participation in the program.
3. The program occurs on a calendar year basis and renews/resets on January 1 of each year as may be determined by CMC.
4. The program can be edited or altered at any time by CMC with or without notice.
5. If I sign up to participate and submit wellness activities for points in a calendar year, I will automatically be renewed to participate in the following/new year unless I otherwise notify the program staff.
6. Failing to earn/submit for any wellness points in a given calendar year will result in my not being automatically renewed for the program the following year. Instead, if I desire to renew, I would need to complete a new Participation form.
7. My confidential employee data that I may submit as part of the points earning process, including my Protected Health Information, will only be reviewed by and for the following purposes:
   1. An Employee Health Services Nurse or Wellness program professional for the purpose of reviewing my free CMC lab work and to meet with me to review the results.
   2. An Employee Health Services Nurse or Wellness program professional for the purpose of contacting me with any concerns for proactive coaching or advice as it may relate to conditions that may become apparent because of the lab work review or otherwise during the course of participation in the program.
8. My employee data including my Protected Health Information will be treated under strict confidentiality protocols and will never be shared/disclosed with any other CMC team member, other than as indicated above in section 7.
9. CMC seeks to follow regulations and rules that might be associated with offering a Wellness Program:
   • ADA & HIPAA nondiscrimination – CMC believes the components of the plan have a reasonable chance of promoting health or preventing disease, but aren’t overly burdensome, are voluntary with intent for participants to understand what medical information will be obtained and for what purpose and who will see it. It is the intent to reasonably accommodate employees who need it to access the program.
   • GINA – CMC won’t require or reward the submission of family medical history information and will maintain confidential medical records & follow strict limits as it relates to non-disclosure of genetic information.
   • HIPAA Privacy and Security- CMC won’t negatively discriminate in health coverage based on a health factor as it relates to eligibility.
   • Title VII & Age-CMC will avoid taking into consideration race, religion, sex, color, age, or national origin as it pertains to program rewards.
   • Mental Health Parity and Addiction Equity ACT (MHPAEA) requires equal footing for surgical/medical and mental heath/substance abuse treatments.

10. It is the intent to reasonably accommodate you if needed to access the program, so I will ask and discuss if something is not accessible to me, and CMC will try to determine a reasonable alternative standard if at all possible.
11. CMC will tax cash earnings as may be required by the IRS or other state/local entities and will be reported on my W-2 as required.
12. The out-of-pocket cost, such as insurance co-pays, to complete activities like specific medical exams other than those specified as “free” under the program are my responsibility and are not paid for by CMC.
13. The program is voluntary so I can end participation any time I want by simply ceasing to complete activities and/or not turning in the “Passport” requesting review of activities for points/financial award.
14. If I qualify for wellness points conversion to a financial award and I don’t choose one of the two financial payment routes as indicated on the “passport” I will be defaulted to receiving a check or direct deposit as CMC may determine.
15. CMC makes no warranty as it relates to the effect Wellness payments will have on eligibility for other nonrelated programs or benefits administered by a State or Federal government or other entity. I acknowledge responsibility to research and understand the effects of such payments as it may be related.
16. I understand and agree that neither CMC nor their employees, Board, or volunteers shall assume or have any responsibility or liability for expenses or medical treatment or for compensation for any injury I may suffer during or resulting from my voluntary participation in any and all CMC Wellness program activities. I do hereby for myself, my heirs, executors and administrators, waive, release, and forever discharge any and all rights and claims for damages that I may have or that may hereafter accrue to me arising out of or in any way connected with my participation in this program.
17. I understand that I have been advised to seek consultation from my doctor about whether I can safely participate in this program and whether there are precautions or limitations to my participation.