Biometric Screening Form

Know your numbers, know where to start – in just three easy steps.


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1. Visit your provider for an annual physical – covered 100 percent by your health plan.

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2. Ask your provider to complete the biometric screening form and the authorization to use or disclose protected health information form.

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3. Return the biometric screening form and the authorization to use or disclose protected health information form to the Center for Healthy Living.


The Center for Healthy Living on Purdue’s West Lafayette campus strives to help individuals get, stay and be well. A new initiative of the center is to increase the collection of biometric data from patients. When employees know their numbers they can then take advantage of the multitude of no-cost resources the center has to offer specific to their needs.

“Biometric screenings provide vital health information,” said Millie Fenneman, practice administrator at the center. “The collection of biometric data will help us better understand the needs of our population as a whole and track our progress in providing the right resources to help our Purdue community live a healthier, more vital life. Our patients’ health and privacy are our priorities. All data will be collected by Premise Health, the company that manages the Center for Healthy Living. Purdue will not have access to individual data.”

According to Eva Nodine, benefits director in Human Resources, establishing care with a primary care provider and making sure annual physicals are completed is the best combination for employees to successfully manage their health. An annual physical is also the prime time to have biometric data collected.

The center’s services are offered to all benefits-eligible faculty and staff, including those who opt out of Purdue medical coverage, and their covered dependents. Preventive care – including annual physicals - and wellness workshops are among the services offered at no charge.

Preventive care is covered at 100 percent by all Purdue medical plans, regardless of where care is provided. The center’s staff works collaboratively with outside providers to help ensure patients get the best overall care including supplemental, complementary care available at the center.

“We encourage our employees to get their annual physicals and utilize preventive care service wherever it makes the most sense for them to do so,” Nodine said. “Allowing Premise to utilize their biometric data adds additional benefit to their health as the center would be able to provide additional complementary support and care tailored to an employee’s specific needs through wellness workshops, health coaching, dietitian services and more. It’s a win-win for our employees and their health.”

In order for the Center for Healthy Living to utilize an employee’s biometric data, employees should do the following:

  1. Visit their provider for an annual physical – covered 100 percent by their Purdue health plan.
  2. Ask their provider to complete both the biometric screening and authorization to use or disclose protected health information forms from the Center for Healthy Living.
  3. Return both forms to the Center for Healthy Living or ask the provider to submit both forms directly via secure fax at 765-496-6656.

The biometric screening form is utilized to record measurements of the following elements:

  • Height, weight, waist circumference, BMI;
  • Cholesterol: total cholesterol, LDL, HDL, triglycerides;
  • Glucose: fasting plasma; and
  • Blood pressure.

Once the forms are received at the Center for Healthy Living, a certified health coach will review the employee’s information, contact the employee and discuss any services the center could provide to the employee that would provide additional support and information specific to each individual. The certified health coach will ask the employee to review and sign the Center for Healthy Living’s Patient Acknowledgment of the Notice of Privacy Practices, if they have not had a prior visit to the center. If an employee’s provider submits the screening and authorization forms on the employee’s behalf, the employee is encouraged to contact the center seven to 10 days following his or her appointment to ensure the forms were received.

For questions about the biometric screening form utilization, contact Tammy Ridge, health center manager, at 49-45505.



Biometric Screening Form

Authorization to use or disclose protected health information forms

Patient Acknowledgement of the Notice of Privacy Practices

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