Enroll | Tria Health

1. Demographic & Preferred Contact Information

Last Name

First Name

MI

Address

City

State

Zip

Primary Phone

Primary Phone Type

Secondary Phone

Secondary Phone Type

Preferred Time of Contact

Preferred Method of Contact

Email Address

Confirm Email Address

Date of Birth

Gender

Height Feet

Height Inches

Weight (in pounds)

Employer / Benefits provided through

2. Provider Information

Primary Physician Name

Phone

City

State

Additional Physician Name

Phone

City

State

Additional Physician Name

Phone

City

State

3. Medication Allergies & Adverse Reactions

Medications

Adverse Reaction

4. Current Medications & Medical Conditions

Medications

Dosage

Directions for Use

Reason for Taking

5. Lifestyle Habits

Do you smoke tobacco?

For members who smoke
1. How soon after you wake up do you smoke your cigarette?	< 5 minutes	6 to 30 minutes	31 to 60 minutes	> 60 minutes
2. Do you find it difficult to refrain from smoking in places where it is forbidden (for example, movie theater and church)?	Yes	No
3. Which cigarette would you most hate to give up?	The first one in the morning	Any other
4. How many cigarettes per day do you smoke?	10 or fewer	11 - 20	21 - 30	31 or more
5. Do you smoke more often during the first hours after waking than during the rest of the day?	Yes	No
6. Do you smoke if you are so ill that you are in bed most of the day?	Yes	No

Do you use smokeless tobacco products?

For members who use smokeless tobacco
1. How many tins or pouches of smokeless tobacco do you typically use per week?	< 1	2 to 4	>= 5
2. How often do you use smokeless tobacco?	< 1 day/week	2 - 5 days/week	>= 6 days/week
3. Do you intentionally swallow tobacco juices?	Yes	No
4. Do you use smokeless tobacco when you are sick or when you have sores in your mouth?	Yes	No
5. How soon after you wake up do you use chewing tobacco or snuff?	< 30 mins	> 30 mins
6. Do you smoke cigarettes?	Yes	No
7. Do you find it difficult not to use smokeless tobacco when it is not allowed?	Yes	No

Please indicate using the scale below how motivated you are to quit using tobacco.

Not at all motivated				Extremely Motivated

6. Past Medical & Surgical History

Medical History

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Please explain any responses selected above:

Surgical History

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Please explain any responses selected above:

7. Additional / Overflow Information

Please include any additional relevant information that may allow us to better assist you.

8. Privacy Policy & Signature

Our Commitment to Your Privacy

Tria Health is dedicated to maintaining the privacy of your health information. This describes our privacy practices, your legal rights and lets you know how Tria Health is permitted to

Use and disclose PHI about you
How you can access and copy that information
How you may request amendment of that information
How you may request restrictions on our use and disclosure of your PHI

Use and disclosure of your health information in certain special circumstances. The following circumstances may require Tria Health to use or disclose your health information:

To public health authorities and health oversight agencies that are authorized by law to collect information.
Lawsuits and similar proceedings in response to a court or administrative order.
If required to do so by a law enforcement official.
When necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. We will only make disclosures to a person or organization able to prevent the threat.
If you are a member of the U.S. or foreign military forces (including veterans) and if required by the appropriate authorities.
To federal officials for intelligence and national security activities authorized by law.
To correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official.
For Workers Compensation and similar programs.

Your rights regarding your health information

Communications. You can request that Tria Health communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work. We will accommodate reasonable requests.
You can request a restriction in our use or disclosure of your health information for treatment, payment, or health care operations. Additionally, you have the right to request that we restrict our disclosure of your health information to only certain individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request, however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you
You have the right to inspect and obtain a copy of the health information that may be used to make decisions about you, including patient medical records and billing records, but not including psychotherapy notes. You must submit your request in writing to Jessica Lea, President of Tria Health.
You may ask us to amend your health information if you believe it is incorrect and incomplete and as long as the information is kept by or for our pharmacists. To request an amendment, your request must be made in writing and submitted to Jessica Lea, President of Tria Health. You must provide us with a reason that supports your request for an amendment.
Right to a copy of this policy. You are entitled to receive a copy of Tria Health’s Privacy Policy. You may ask us to give you a copy at any time. To obtain a copy of this policy, contact the Tria Help desk at 1.888.799.8742
By signing the above enrollment form, I acknowledge receipt of Tria Health’s Privacy Policy and a copy is available upon request by calling the Tria help desk, 1.888.799.TRIA (8742).

I acknowledge receipt of the Tria Health Notice of Privacy Practices as contained in this Enrollment Form, and I understand that a copy may be emailed to me and is also available upon request by calling Tria Health at 1.888.799.TRIA (8742). I authorize Tria Health and its pharmacist(s) and designated employees to release to my health care providers (as identified above or otherwise learned by Tria Health from time to time) any medication or other information about me which is related to my medical treatment and/or continuity of care, unless I state otherwise in writing. I further understand that all information contained on this enrollment form (e.g., phone numbers, email addresses, medical information) and otherwise revealed through my encounters with Tria Health will remain strictly confidential, and will only be used or disclosed for purposes of payment, treatment or health care operations, including without limitation for the purpose of communicating with my health care providers and me as a part of the services offered through the Tria Health program.

I have read and understand the privacy policy

E-Signature:

Date E-Signed:

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