WELLNESS PROGRAM CENTRAL STATE UNIVERSITY - Participate in your Wellness Program this
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WELLNESS PROGRAM
CENTRAL STATE
UNIVERSITY
Participate in your Wellness Program this
year to earn a premium differential in 2022.
WELCOME TO YOUR
2021 WELLNESS PROGRAM!
Medically-enrolled employees can complete steps 1-3 below by OCTOBER 15, 2021 to earn a premium
differential. Your new program details are outlined in this guide.
STEPS TO EARN THE PREMIUM DIFFERENTIAL
STEP 1: PHYSICIAN RESULTS FORM
Complete an annual physical exam with your physician between DEC EMBER 1 , 2020 and OC TOBER 15, 2021. Take this
packet with you to your appointment and have your doctor complete and sign the Physician Results Form. It is the
participant’s responsibility to return the form as part of the completed packet by OC TOBER 15, 2021.
• Have you already received your annual physical within the above timeframe? Take or send the Physician Results
Form to your physician’s office to have it signed and completed.
If you do not have a doctor, you can select a doctor within the Central State University health benefit plan network. If you
need assistance in finding a physician, please go to w w w .aetna.com. Little clinics and minute clinics do not qualify as
Primary Care Visit completion.
STEP 2: TOBACCO ATTESTATION FORM/CESSATION PROGRAM
All participants are required to complete this form in its entirety and certify that they are a non-tobacco user or are a
tobacco user that will complete the Wellworks For You 6-week Tobacco Cessation e-Learning Series.
• If you certify that you do not use tobacco, you will complete Step 2 by completing the Tobacco Attestation Form.
• If you certify that you use tobacco, you must complete the Tobacco Cessation e-Learning Series by
OC TOBER 15, 2021 to earn credit for this requirement. Instructions to complete the 6-week e-Learning Series
are located on the Tobacco Attestation Form.
STEP 3: SUBMIT YOUR COMPLETED FORMS BY OCTOBER 15, 2021
For submission requirements, please refer to page 6 of this guide.
Submission via email will result in an immediate confirmation that your form was received. Any other means of submission require you
to log into your Wellness Portal to confirm your form was processed.
IMPORTANT! New Hire Requirements
• If you are hired on or before SEPTEMBER 1, 2021 you are eligible to complete the
requirements.
• If you are hired after SEPTEMBER 1, 2021 you are not eligible for the 2022
incentive.
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Central State University 2021 Wellness Program | Phone: 800.425.4657 | www.wellworksforyoulogin.comLOG INTO YOUR
WELLNESS PORTAL
Your account credentials have already been generated for you.
You do not need to create a new account. Use the username and
password formats below to log into the Wellness Portal.
LOG INTO THE WELLNESS PORTAL
1. Go to www.wellworksforyoulogin.com
2. Your account credentials are listed below
MEMBER TYPE USERNAME FORMAT PASSWORD FORMAT EXAMPLE
UN : CSU000123456
Employee CSU + Employee ID Birthdate in M M DDYYYY
PW : 0 4131980
PLEASE N OTE: The temporary password is only for the first time you access the Portal and you will be prompted to change it
upon entry. If you have accessed the Wellness Portal in the past, you should continue to use your existing password.
FORGOT YOUR USERNAME OR PASSWORD?
1. Go to www.wellworksforyou.com
2. Select the Forgot Username or Forgot Password link
3. Enter your email address to initiate the password reset process or retrieve your username
VIEW DETAILS FOR PROGRAMS, EVENTS, AND ACTIVITIES
Events are listed on your personal Wellness Portal within ResultsNow. You can access this via the ResultsNow section on the
homepage or via the MENU page. To view more details about a program component, select Click for Details. If there are sub-
events associated with a component, they will display in the pop-up. Click the + and – buttons to expand or minimize the
details of the sub-events.
VIEW YOUR PARTICIPATION
Wondering what you have completed to date?
1. Log into your Wellness Portal (www.wellworksforyoulogin.com)
2. View your program status right on the homepage!
3. For more details, click an icon within the ResultsNow section of the homepage or use the Portal MENU to access the
ResultsNow page
4. A large green check mark will display over the icon once the component’s requirements are complete
5. Click an icon or select Click For Details to view a list of available options for each program component
6. A small green check mark will be visible in the Completed column once an event is complete
VIEW AND DOWNLOAD DOCUMENTS FOR COMPLETION
All forms are located in your Wellness Portal within the W ellness Locker accessed
via the Portal M EN U or homepage section. Download and/or print PDF forms for completion.
SMARTPHONE
The Wellworks For You Portal App includes all of your favorite features from the Portal including
recipes and grocery lists, programs and events listings, ResultsNow incentive tracking, and more!
Simply search for Wellworks For You in the Play Store or App Store to download the free App.
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Central State University 2021 Wellness Program | Phone: 800.425.4657 | www.wellworksforyoulogin.comF OR WW OFFICE USE ONLY: 002PR_AP_CR_12407
PHYSICIANS RESULTS FORM
Take this form with you to your scheduled annual physical to be completed and signed by your primary care physician. It
is the p articipant’s responsibility to submit the Physician Results Form as part of the wellness program to Wellworks For
You, as outlined below, by OCTOBER 15, 2021. Please retain a copy for your own records and submission to Wellworks
For You.
PATIENT CONTACT INFORMATION
COMPANY NAME: C entral State University
FIRST NAME: LAST NAME:
DATE OF BIRTH: MALE FEMALE
PHONE: EMAIL:
EMPLOYEE ID _ _ ___________________________
PHYSICIAN INFORMATION
PHYSICIAN OFFICE/NAME:
OFFICE PHONE/ADDRESS:
This Physician Results Form confirms that the patient named above received the following preventative care between
DEC EMBER 1 , 2020 and OC TOBER 15, 2021. The primary care physician needs to complete the information below with
an * in front of it and return the completed form to the patient named above. Does your patient have a
history of coronary artery YES NO
SCREENING RESULTS SCREENING RESULTS disease (MI, CABG, PTCA)?
*Blood Pressure (Systolic) *Total Cholesterol Does your patient have a YES NO
*Low Density history of diabetes?
*Blood Pressure (Diastolic)
Lipoprotein (LDL)
*High Density If no, does your patient have
*Height (in inches) YES NO
Lipoprotein (HDL) pre-diabetes?
*Wai st Circumference (may
*Triglycerides Do you, the physician, plan
be self-reported) on following up with the
*Weight (in pounds) *TC/HDL Ratio patient about their results, YES NO
medication adherence, or
BMI (Body Mass Index) *Glucose (fasting) retesting?
HbA1c (if physician
Pulse (Heart Rate)
recommended)
Physician
I certify that the patient listed above received the tests indicated on this form on: ______/______/_________
Physician Signature: ________________________________________________ Date Signed: _____________________
SUBMIT YOUR COMPLETED FORM BY OCTOBER 15, 2021
All forms should be submitted to the Wellworks Forms Department. Submit your completed forms in one (1) of the following ways:
• Sc an and email: forms@wellworksforyou.com
• Up load to Portal: In R esultsNow, select the event you would like to upload your form for, click the Attach File button to select a file
from your computer. Users are limited to on e (1) file per email.
• Up load to Mobile App: Take a photo of your form using your Smartphone, and upload it to the Wellworks For You Mobile App on the
Con tact Us Page.
• M a il: 70 East Lancaster Ave, Frazer, PA 19355, Attention: Forms Department
PL EASE NOTE: Submission via email will result in an immediate confirmation that your form was received.
Any other means of submission require you to log into your Wellness Portal to confirm your form was processed.
4
Central State University 2021 Wellness Program | Phone: 800.425.4657 | www.wellworksforyoulogin.com
Phone: (800) 425-4657 www.wellworksforyoulogin.comF OR WW OFFICE USE ONLY: 002PR_AP_CR_12407
TOBACCO ATTESTATION FORM
Whether or not a tobacco user, every participant is required to complete and sign the below affidavit to certify that he or she is
tobacco-free, OR a tobacco user who will complete the Wellworks For You Tobacco Cessation e-Learning Series (considered a
Reasonable Alternative Standard) to quality for the premium differential It is the participant’s responsibility to submit the
Tobacco Attestation Form as part of the wellness program to be returned to Wellworks For You, as outlined below, by
OC TOBER 15, 2021.
CONTACT INFORMATION
COMPANY NAME: C entral State University
FIRST NAME: LAST NAME:
DATE OF BIRTH: MALE FEMALE
PHONE: EMAIL:
EMPLOYEE ID _ _ ___________________________
TOBACCO STATUS (PLEASE CHECK ONE):
I do not use tobacco products, including cigarettes, cigars, chewing tobacco, e-cigs, or any other nicotine product and promise
not to use these products during this benefit year. I understand that I may be subject to tobacco-use testing.
I currently use tobacco products, but will be completing the W ellworks For You 6 -week Tobacco Cessation e-Learning Series by
OC TOBER 15, 2021.
I currently use tobacco products and w ill not be completing a cessation program.
NOTE: You will not qualify for the incentive if you are currently using any form of tobacco, including cigarettes, cigars, e-cigs, and chewing
tobacco, in any amount – even occasional social use – and choose not to participate in the Cessation Program as the Reasonable
Alternative Standard.
How to Complete the Tobacco Cessation 6-week e-Learning Series:
You must login to your Wellness Portal account, select the Portal M ENU option and navigate to the e-Learning page and select
e-LS: Tobacco Cessation. After completing the Pre-Module Survey, Module 1 will unlock. Beginning with Module 1, you must
watch each video and then complete the quiz associated with each module. You must pass each quiz with a score of 70% or
above to move on to the subsequent Module. Each Module will unlock after exactly one week of passing a Module’s quiz. After
you complete Module 6, you must complete and save the Post-Module Survey. You must begin this program (including all
quizzes and surveys) no later than AUGUST 15, 2021 to complete the program in its entirety by OC TOBER 15, 2021.
PLEASE SIGN BELOW
I understand this is a legally binding document and I attest that the above information is accurate to the best of my knowledge.
This attestation form is not complete unless I have checked a box in the Tobacco Status section that is relevant to me and
have signed and dated the form below.
Signature of Participant (Required) Date
SUBMIT YOUR COMPLETED FORM BY OCTOBER 15, 2021
All forms should be submitted to the Wellworks Forms Department. Submit your completed forms in one (1) of the following ways:
• Sc an and email: forms@wellworksforyou.com
• Up load to Portal: Click Contact Us on the main menu bar of the Portal, or via the Portal M ENU, and use the Attach File button to
select a file from your computer. Users are limited to on e (1) file per email.
TOBACCO ATTESTATION FORM
• Up load to Mobile App: Take a photo of your form using your Smartphone, and upload it to the Wellworks For You Mobile App on the
Con tact Us Page.
• M a il: 70 East Lancaster Ave, Frazer, PA 19355, Attention: Forms Department
PL EASE NOTE: Submission via email will result in an immediate confirmation that your form was received.
Any other means of submission require you to log into your Wellness Portal to confirm your form was processed.
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Central State University 2021 Wellness Program | Phone: 800.425.4657 | www.wellworksforyoulogin.com
Phone: (800) 425-4657 www.wellworksforyoulogin.comSUBMIT YOUR COMPLETED FORMS
SUBMIT YOUR COMPLETED DOCUMENTS BY: OCTOBER 15, 2021
All forms should be submitted to the Wellworks Forms Department. Submit your completed forms in one (1) of the following ways:
• Scan and email: forms@wellworksforyou.com
• Upload to Portal: In ResultsNow, select the event you would like to upload your form for and click Attach File
• M ail: 70 E Lancaster Ave, Frazer, PA 19355, Attention: Forms Department
• Sm artphone App: Take a photo of your document on your Smartphone, open your Wellworks For You App, select C ontact
Us, and upload your file
PLEASE NOTE: Submission via email will result in an immediate confirmation that your forms were received. Any other means of
submission require you to log into your Wellness Portal to confirm your forms were processed. Wellworks For You requires at least
7 -1 0 business days for processing and participation to be updated in the Wellness Portal. If you do not receive a confirmation
email in two (2) weeks from submission, please log into your Wellness Portal account to confirm incentive progress. Please keep
a copy of all forms for your files.
CONTACT YOUR WELLNESS TEAM
ASK A QUESTION VIA EMAIL: For any questions about your Wellness Program, please email core@wellworksforyou.com and
a member of our Core Team will be able to assist you.
ASK A QUESTION FROM THE PORTAL OR SMARTPHONE APP: Select C ontact Us from the Portal homepage or Wellworks
For You mobile app and submit your question and a member of our Core Team will be able to assist you.
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Central State University 2021 Wellness Program | Phone: 800.425.4657 | www.wellworksforyoulogin.comTHE FINE PRINT
The Central State University wellness program is a voluntary wellness program available to all employees covered by the
medical plan. The program is administered according to federal rules permitting employer-sponsored wellness programs
that seek to improve employee health or prevent disease, including the Americans with Disabilities Act of 1990, the Genetic
Information Nondiscrimination Act of 2008, and the Health Insurance Portability and Accountability Act, as applicable,
among others. If you choose to participate in the wellness program, you will be asked to complete a Physician Results Form,
which will include a blood test for blood pressure, height, weight, waist circumference, BMI, lipid panel and glucose. You are
not required to participate in the blood test or other medical examinations. However, eligible employees who choose to
participate in the wellness program will receive an incentive of a premium differential effective as of 2022 for submitting a
completed Physician Results Form and a Tobacco Attestation Form by October 15, 2021.
If you are unable to participate in any of the health-related activities or achieve any of the health outcomes required to earn
an incentive, you may be entitled to a reasonable accommodation or an alternative standard. You may request a reasonable
accommodation or an alternative standard by contacting Wellworks For You at 800-425-4657.
The information from your results will be used to provide you with information to help you understand your current health
and potential risks, and may also be used to offer you services through the wellness program. You also are encouraged to
share your results or concerns with your own doctor.
PROTECTIONS FROM DISCLOSURE OF MEDICAL INFORMATION
We are required by law to maintain the privacy and security of your personally identifiable health information. Although the
wellness program and Central State University may use aggregate information it collects to design a program based on
identified health risks in the workplace, Wellworks For You will never disclose any of your personal information either
publicly or to the employer, except as necessary to respond to a request from you for a reasonable accommodation needed
to participate in the wellness program, or as expressly permitted by law. Medical information that personally identifies you
that is provided in connection with the wellness program will not be provided to your supervisors or managers and may
never be used to make decisions regarding your employment.
Your health information will not be sold, exchanged, transferred, or otherwise disclosed except to the extent permitted by
law to carry out specific activities related to the wellness program, and you will not be asked or required to waive the
confidentiality of your health information as a condition of participating in the wellness program or receiving an incentive.
Anyone who receives your information for purposes of providing you services as part of the wellness program will abide by
the same confidentiality requirements. The only individual(s) who will receive your personally identifiable health information
are the Wellworks For You team in order to provide you with services under the wellness program.
In addition, all medical information obtained through the wellness program will be maintained separate from your personnel
records, information stored electronically will be encrypted, and no information you provide as part of the wellness program
will be used in making any employment decision. Appropriate precautions will be taken to avoid any data breach, and in the
event a data breach occurs involving information you provide in connection with the wellness program, we will notify you
immediately.
You may not be discriminated against in employment because of the medical information you provide as part of
participating in the wellness program, nor may you be subjected to retaliation if you choose not to participate.
If you have questions or concerns regarding this notice, or about protections against discrimination and retaliation, please
contact Wellworks For You at 800-425-4657.
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