EHP Tobacco

Health plan ID**

Aetna members please enter your 12 digit W number from your Aetna card. Include the "W" and all 11 numbers. Exclude spaces and dash. (Ex: W12345678901). Florida/UMR members please enter your 10 digit Medical ID card number (make sure your two-digit suffix is included). If you can’t locate your card, you can access your number in the healthy choice portal dashboard. Please check your number for accuracy, inaccurate numbers can lead to delays.

Member Name*

First Name

Last Name

Relationship to the primary EHP member*

Employee Name (Must include if dependant is joining.)*

First Name

Last Name

Email*

Preferred email address to receive emails from your coach.

Address*

Address Line 1

City

State

ZIP Code

Phone*

Date of Birth*

Gender*

Male Female Prefer Not to Answer

Terms and Conditions*

I accept these terms and conditions

The Cleveland Clinic eCoaching Program (hereafter referred to as PROGRAM) is designed to help individual participants improve healthy behavior, achieve and maintain behavior change goals and reduce the risk of chronic disease. The PROGRAM will provide email education regarding chronic disease conditions; physical activity options; as well as proper nutrition, stress management and tobacco cessation techniques (if applicable). PRIOR TO ENTERING THE PROGRAM, THE UNDERSIGNED PARTICIPANT SHALL SEEK MEDICAL ADVICE FROM HIS OR HER PHYSICIAN TO BE CLEARED FOR THE ACTIVITIES ASSOCIATED WITH THE PROGRAM. THE CLEVELAND CLINIC IS NOT RESPONSIBLE FOR THE PARTICIPANT’S FAILURE TO ENGAGE HIS OR HER PHYSICIAN IN THIS MANNER OR FOR ANY DAMAGE THAT MAY RESULT FROM THE PARTICIPANT’S FAILURE TO DO SO. Further, I understand that eCoaching utilizes Transport Layer Security (TLS) encryption for its email communications. If my email provider does not support TLS my emails will come via a link to an encrypted web portal. I may also request of my coach to flag my account to use a secure portal regardless if my email provider supports TLS or not. Failure to complete the program requirement of obtaining the pre and post weight will result in financial responsibility for the program and ineligibility for future programs. If you are unable to fulfill your obligation due to medical reasons, you will need to notify EHP. The Cleveland Clinic does not warrant the results of the program.

AUTHORIZATION FOR RELEASE OF INFORMATION*

I agree to participate in the program and provide a cotinine test as verification of participation and tobacco cessation. I understand this information is necessary for coverage of the program. This information is confidential but will be used to report completion of the program. NOTE: I understand that participation will terminate upon termination of employment, if I cease to be a member of the EHP, or if I do not meet program requirements. TYPE YOUR NAME ABOVE. THIS CONSITUTES AS AN ELECTRONIC SIGNATURE THAT IS REQUIRED BY LAW.