TCL (Tri-Cities Laboratory) Biometric Lab Screening Slip Account Name: Biometric Screening Kadlec

1. TCL (Tri-Cities Laboratory) • Biometric Lab Screening Slip • Account Name: Biometric Screening Kadlec • Account Number: BIOSK Patient ID:BIOSK++ • Instructions: • In order to obtain services, take this lab slip to any TCL Lab location beginning 1/2/14 through 2/28/14. Search for locations at http://www.tricitieslab.com. • Lab work CANNOT be completed at the Kadlec Medical Center Lab. • You must be fasting for 8-10 hours prior to labs being drawn. A urine sample is also taken, so Pleasedrink plenty of water! • Present picture ID at the time of service. • Include your Kadlec Health Plan Member ID number on the form below. 8 7 0 1 8 7 0 2 The above Kadlec employee or spouse/domestic partner (DP) of the employee is authorized for the biometric screening tests as listed below. Participant: These tests are administered for your biometric screening.Kadlec does not receive, review or interpret these results. • Complete the following threeWellness Requirements, in any order, on or before the 2/28/2014 Open Enrollment screening deadline in order to: 1) avoid a $100/month per person non-wellness fee* (for you and your covered spouse/DP); and 2) earn additional HRA dollars. Three wellness requirements as follows: • Complete your Biometric Screening Labs (as authorized on this form ) • Complete Online Member Health Assessment(access website at www.kadlecwellness.com - site is available from 1/2/14 to 2/28/14) • Meet with a Kadlec Health Coach. (schedule online at www.kadlecwellness.com) • *Reminder! By completing all three Wellness requirements on or before 2/28/14, you and your enrolled spouse/domestic partner will earn extra $250 Health Reimbursement Arrangement (HRA) dollars. If a tobacco user; a $50 monthly tobacco usage fee will apply starting 4/1/14. Signature x ___________________________________________________ Date _______________________ By signing this lab slip, I am verifying that I am a newly eligible participant for Kadlec’s Basic and/or Enhanced Health Plans, or this form is being used during the annual open enrollment screening, and I qualify for the Biometric Screening Lab test. I also understand if I am not an eligible participant, I will be responsible for charges incurred.

2. Biometric Screening Checklist (Participant – Keep this Checklist and follow the steps below) Process and Instructions • Covered Employee & Covered Spouse/Domestic Partner • $$ - Earn more HRA dollars by completing the following three Wellness Requirements by 2/28/2014 • Complete the following threeWellness Program Requirements, in any order, on or before the 2/28/2014 Open Enrollment screening deadline in order to: • avoid a $100/month per person non-participation fee (for you and your covered spouse/DP) • earn additional HRA dollars. • Three wellness requirements as follows: • Complete your Biometric Screening Labs (as authorized on this form) – beginning 1/2/2014 through 2/28/2014. • Complete Online Member Health Assessment access Viverae website at www.kadlecwellness.com. Online Member Health Assessment is available from 1/2/2014 to 2/28/2014. • Meet with a Kadlec Health Coach. To meet with a Kadlec Health - schedule your appointment (online) at www.kadlecwellness.com. The online scheduling system will be available starting 1/2/2014. • *Reminder! By completing all three Wellness requirements timely, you and your enrolled spouse/domestic partner will earn extra $250 Health Reimbursement Arrangement (HRA) dollars. If a tobacco user; a $50 monthly tobacco usage fee will apply starting 4/1/2014. • Note: If you need assistance with your Health Assessment, please contact Viverae@ 1.800.848-3723. • If you do not know your First Choice Member ID (located on insurance card), please contact First Choice Health at 1-866-395-0212.