Physician Waiver & Attestation
Note to Patient’s Physician
The Karelia Health Risk Reduction Education program is an employer-sponsored wellness
program designed to promote good health and help participants prevent or better manage
chronic disease by making appropriate lifestyle changes. To encourage participants to take
beneficial steps to maintain and improve their health, your patient’s employer provides
incentive rewards for participating in the Karelia worksite health education program.
The Karelia program includes a confidential health screening (fasting venous blood draw with
Lipid Panel, Glucose/HbA1c, BP and Weight) followed by a series of evidence-based educational
sessions conducted by a Registered Dietitian focused on appropriate therapeutic lifestyle
change. Participants earn incentive rewards for participation in the health screening without
regard to their health status.
Your patient believes that participation in the health screening may be medically inadvisable
because of a known medical condition for which you are treating them.
If you agree that:
1. Participation in a worksite screening program is inadvisable for this patient based on
their medical history/condition, or
2. Participation in a worksite screening program is inadvisable and they have had the same
tests completed at your direction within the last 90 days,
Your patient may request that some or all of the screening requirements be waived and still
earn the full incentive reward from their employer. If, in your medical opinion, either of the
above statements applies to your patient, please complete the reverse side of this form and
return it to them. The patient is responsible for returning all documentation to Karelia Health,
the program administrator.
We appreciate your attention to this matter. Thank you for your assistance and cooperation.
Sincerely,
Karelia Health, LLC
NOTE: Employee is responsible for returning all documentation to the Program Administrator.
Mail: Karelia Health, Greenwich Information, 5 Batterson Park Rd., Farmington, CT 06032
Email: GreenwichWellness@kareliahealth.com
Phone: 888-930-7451 Fax: (860) 606-9588
Physician’s Attestation
Patient Information
Patient’s Name (Please print):
Physician’s Support of Participation Waiver
Based on my knowledge of this patient’s medical history and/or current health condition, it is my
opinion that participating in a fasting worksite screening is medically inadvisable.
This patient completed a laboratory screening test at my direction within the last 90 days and I
agree that participation in a fasting worksite screening is medically inadvisable at this time. Waiver
must include patient’s lab sheet from the recent test, or if unavailable, Physician’s attestation as to
those recent lab values below.
Cholesterol:
mg/dL
Triglycerides:
mg/dL
Glucose:
mg/dL
Blood Pressure- Systolic:
LDL:
mg/dL
HDL:
HbA1c (if applicable):
mm Hg Diastolic:
mm Hg
Practice Name:
Physician’s Name:
Physician’s Signature:
Date:
NOTE: Employee is responsible for returning all documentation to the Program Administrator.
Mail: Karelia Health, Greenwich Information, 5 Batterson Park Rd., Farmington, CT 06032
Email: GreenwichWellness@kareliahealth.com
Phone: 888-930-7451 Fax: (860) 606-9588
mg/dL