This form is used to determine:
- If you are an employee of an employer who is qualified to participate in the Health Connector for Business’s wellness rebate program, CONNECTWELL (the “Program”), and
- If the information you entered matches that of an employee of a qualified employer.
By submitting this form, you certify that you:
- Are the person whose information you have entered or that you have been authorized to enter that person’s information
- Believe you are an employee of a qualified employer
- Are seeking to confirm your eligibility for a reward under the terms of the Program, and that you have no other purpose.
By submitting this form you agree that the Health Connector will retain any information you enter, and use it to determine if you are an employee of a qualified employer. This form will not display or disclose any personally identifiable information. Notwithstanding that fact, you agree that you will not use this form to seek to access any personally identifying information of others. The Health Connector for Business monitors use of this form, including all actions that you may take related to it. Your use of this form constitutes your express consent to such monitoring.
By submitting this form and any accompanying documentation to the Health Connector for Business, you are certifying that you understand and agree with the following statements:
- The Health Connector for Business requires information about you in order to determine that you are an employee of a qualified employer and that you have completed the necessary activity to qualify for a reward under the Health Connector for Business’ wellness program, CONNECTWELL the “Program”). This includes information that may identify you and other personal information, such as medical information, that may be contained in the documents you submit.
- The Health Connector will keep the information you provide private and will only use or disclose it for the purposes of administering the Program, as authorized by M.G.L. c. 176Q § 7A, or as may otherwise be required by law.
- The Health Connector for Business is solely responsible for the final determination regarding who is eligible for a reward under the Program.
- You certify under the pains and penalties of perjury that you are the person who is the subject of the information submitted or that you have been authorized to enter that person’s information, and that the information you are providing is true and complete to the best of your knowledge.