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CareConnect Insurance Company, Inc.

BASIC HEALTH INFORMATION

1. What is your current weight: Pounds

2. What is your current height: Feet Inches

3. Are currently you pregnant? K Yes K No (If male please skip to question 5)

4. Have you recently given birth? K Yes K No

If so, when was the date?

5 Do you see a doctor for routine care? K Yes K No

What is your doctor’s name?

What is your doctor’s phone number?

When was the last time you saw this doctor? / /

6. If you do not have a doctor that you see for routine care, would you like us to help you find a doctor?

K Yes K No

7. Is your blood pressure: K High K Low K Normal K Not sure

Health Risk Assessment

MEMBER INFORMATION

First Name: ____________________________________________ Last Name:

CareConnect Member ID: ________________________________ Gender: _______________ Date of Birth _____________________

“I understand that: in completing this HRA, I will be sharing my health information and may receive a follow-up call, letter or email

if CareConnect has recommendations about my health and wellness; my health information will be kept private under the terms

of the privacy policy at CareConnect.com and I am not required to complete this HRA, but if I do, I will be entitled to a $50 gift card.

By checking the box below I voluntarily consent to share my health information.”

K I, _______________________________________________________________________ consent to share my health information

______________________________________________________________________________ ____________________________ Signature Date

Please return a completed copy of this form to CareConnect by: Email: [email protected] Mail: CareConnect, Attn: Medical Management-HRA, 2200 Northern Blvd, Suite 104, East Hills, NY 11548

Thank you for taking the time to complete this Health Risk Assessment (HRA). By answering the questions that follow, we can better understand your health care needs and help you meet them. After you complete and submit the HRA, we may call or email you if we have recommendations on your health and wellness. We’ll also send you a $50 gift card. If your spouse is covered under your CareConnect plan, he or she can also complete an HRA and receive a $50 gift card.

CareConnect Insurance Company, Inc.

Health Risk Assessment

8. Have you had a Total Cholesterol Test completed? (blood test) K Yes K No If yes, did your doctor tell you what your total Cholesterol is? K At a good level which usually means that it is under 200 K At a not so good level which usually means that it is between 200-239 K At a poor level which usually means that it is greater than 240 K Not sure

9. Have you had an HDL Cholesterol level completed? (blood test) K Yes K No If yes, did your doctor tell you that your HDL Cholesterol is: K At a good level which usually means greater than 60 K At a not so good level which usually means between 41-59 K At a poor level which usually means between 30-40 K Not sure

10. Have you had an LDL Cholesterol level completed? (blood test) K Yes K No If yes, did you doctor tell you that your LDL Cholesterol is: K At an excellent level which usually means less than 100 K At a good level which usually means less than 100-129 K At a not so good level which usually means between 130-159 K At a poor level which usually means greater than 160 K Not sure

11. Have you had a Triglyceride level completed? (blood test) K Yes K No If yes, did your doctor tell you that your Triglycerides are: K At an excellent level which usually means less than 150 K At a good level which usually means less than 150-199 K At a not so good level which usually means between 200-499 K At a poor level which usually means greater than 500 K Not sure

12. Have you had a Fasting Blood Glucose level test completed? K Yes K No If yes, did your doctor tell you that your Blood Glucose level is: K Good which usually means between 70-99 K Not so good which usually means between 100-125 K Poor which usually means greater than 126 K Not sure

LIFE STYLE INFORMATION

13. Do you smoke or use any of the following tobacco products? K Cigarettes K Chewing Tobacco K Pipe K Cigar K Smokeless Tobacco K I do not use tobacco products

14. If you smoke cigarettes, how many packs or individual cigarettes do you smoke daily? K Between 1-20 K 1 Pack K 2 Packs K Greater than 2 packs K I do not smoke cigarettes

15. If you smoke cigarettes, are the cigarettes that you smoke filtered? K Yes K No

Health Risk Assessment

CareConnect Insurance Company, Inc.

Health Risk Assessment

16. If you use other tobacco products such as chewing tobacco, cigars, pipes or smokeless tobacco, how often do you use these products?

K 1-2 times daily K 2-5 times daily K Greater than 5 times daily K I do not use other tobacco products

17. Do you currently use or have you in the past used drugs or medications that have not been prescribed by a doctor? K Yes K No

If yes, when was the last time you used the drug(s) or medication(s)? K Within the week K Within the month K Within the year K Greater than a year ago

18. How many alcoholic beverages do you have in a typical week? K 1-2 drinks K 2-4 drinks K 4-10 drinks K Greater than 10 drinks K I do not drink alcoholic beverages

19. Are you currently taking medications prescribed by a doctor? K Yes K No If yes, do you take your medications as prescribed by your doctor (do you take your medications as

frequently and consistently as your doctor has instructed you)?

K Always or almost always K Some of the time K Rarely

20. How often do you exercise or participate in a physical activity? K Daily K 2-3 times a week K Once a week K Rarely

21. On a typical day, how do you travel? K Automobile (car, truck) K Motorcycle K Non-motorized bicycle K Bus or some other form of mass transit

22. How many miles do you usually travel on a typical day? K 10 miles or less K Between 11-30 miles K Greater than 30 miles

NUTRITION

23. Do you eat at least five servings of fruits and vegetables every day (one serving would equal at least one half cup)? K Yes K No

24. How often do you eat at a fast food restaurant? K Less than 3 times per week K Greater than 3 times per week K I do not eat at fast food restaurants

PREVENTION

25. When was the last time you saw a dentist for a regular check-up? K Within the year K Last year K I have not seen a dentist within the past 2 years

26. Do you protect your skin from sun damage by using sunscreen, wearing hats, and/or avoiding tanning booths and sunlamps?

K Never or almost never K Occasionally K Often K Very often K Always or almost always

CareConnect Insurance Company, Inc.

Health Risk Assessment

QUALITY OF LIFE

27. How would you describe your overall physical health? K Excellent K Very Good K Good K Fair K Poor

28. How many hours of sleep do you get at night? K 10 or more K Between 6-8 K Less than 6

29. Do you have good social support such as friends or family? K Yes K No

30. How often do you feel anxious or depressed? K Never or almost never K Occasionally K Often K Very often K Always or almost always

MEDICAL HISTORY

31. Do you have any of the following conditions or medical issues? K Allergies K Chronic pain K High cholesterol K Osteoporosis K Arthritis K Depression K Inflammatory bowel disease K Obesity K Asthma K Diabetes K Kidney Disease K Stroke K Back pain K Heart problems K Lupus K Thyroid disease K Cancer K Heart burn or acid reflux K Liver Disease K Other K Chronic bronchitis K Hepatitis K Migraine headaches K Chronic emphysema K High blood pressure K Multiple Sclerosis

32. Have you had any surgical procedures in the past 12 months? K Yes K No If yes, what was the procedure?

33. Have you had any of the following preventive health screenings completed in the past year? K Colon Cancer Screening K Flu Shot K Mammogram K Cholesterol Check K Blood Pressure Check K Pap Smear K Prostate Exam K Routine Annual Physical

34. In the past 12 months how many times have you visited a doctor or clinic for health care services? K 1 to 2 times K 3 to 6 times K Greater than 6 times K I have not seen a doctor or a gone to a clinic for health services

35. In the past 12 months how many times have you gone to the emergency room? K 1 to 2 times K 3 to 6 times K Greater than 6 times K I have not gone to the emergency room in the past 12 months

36. In the past 12 months how many times have you stayed overnight in a hospital? K 1 to 2 times K 3 to 6 times K Greater than 6 times K I have not stayed overnight in a hospital in the past 12 months

WORK RELATED QUESTIONS

37. In the past year how many days of work have you missed due to a personal illness? K 1 to 2 days K 3 to 6 days K Greater than 6 days K I have not missed any work in the past 12 months because of a personal illness

38. During the past month how often did your health problems affect your productivity while you were working? K Never K Occasionally K Frequently

CareConnect Insurance Company, Inc. (“CareConnect”) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. CareConnect does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

CareConnect:

• Provides free aids and services to people with disabilities to communicate effectively with us, such as:

○ Qualified sign language interpreters

○ Written information in other formats (large print, audio, accessible electronic formats, other formats)

• Provides free language services to people whose primary language is not English, such as:

○ Qualified interpreters

○ Information written in other languages

If you need these services, contact CareConnect’s Senior Director, Quality Improvement.

If you believe that CareConnect has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with:

CareConnect

Senior Director, Quality Improvement

2200 Northern Blvd., Suite 104, East Hills, NY 11548

Phone: 855-706-7545

TTY: 855-226-7318

Fax: 844-447-2525

Email: [email protected]

You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Senior Director, Quality Improvement is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs. gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services

200 Independence Avenue, SW

Room 509F, HHH Building, Washington, D.C. 20201

1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Notice of Non-Discrimination

CareConnect Insurance Company, Inc.

Multi-Language Interpreter Services

CareConnect Insurance Company, Inc.

ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-855-226-7318 (TTY: 711).

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-855-226-7318 (TTY: 711).

注意:如果您使用繁體中文,您可以免費獲得語言援助服務. 請致電 1-855-226-7318 (TTY: 711).

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ATTENZIONE: In caso la lingua parlata sia l’italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-855-226-7318 (TTY: 711).

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ATTENTION: Si vous parlez français, des services d’aide linguistique vous sont proposés gratuitement. Appe- lez le 1-855-226-7318 (TTY: 711).

.(711 TTY:) 7318-226-855-1 ںیرک لاک ۔ ںیہ بایتسد ںیم تفم تامدخ یک ددم یک نابز وک پآ وت ،ںیہ ےتلوب ودرا پآ رگا :رادربخ

PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-855-226-7318 (TTY: 711).

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