Welcome to 9Health Fair Online Registration

Step 1 of 4

THANKS to our sponsor:

This on-line registration and data-repository service made possible in part by a grant from the Burlington Northern Santa Fe Foundation.

Welcome. You are beginning the online registration process for a 9Health Fair. This registration will be good only at the fair location selected below. 

  • Registering online does not guarantee that you will receive faster service at the health fair. However, by completing and printing your registration form and paying (using MasterCard or Visa only) online, you will bypass the registration and cashier lines at the fair.
  • As an online registrant, you will receive an email from 9Health Fair within two weeks after the fair with instructions for viewing your blood screening results in your secure 9Health Fair results account. You will need your Username and Password to access them.
  • Your results will NOT be mailed to you. However, you will be able to view and print them from any computer with a secure internet connection and a printer.
  • It is important that you have only one results account. This means that your results from year to year will all be housed in the same place. For this reason, you will NOT receive any multi-year reports with online registration.
  • Please complete your online registration from a desktop computer or in person at a 9Health Fair location. Online registration is not currently supported from a mobile device (e.g., mobile phones and tablets).

* Please complete these required Fields

Location
* 9Health Fair Location:

 

Login Information
If you have created an online registration account in a previous fair season, Log in now, using the Username and password created at that time.

---- OR ----

If you have never registered online for a 9Health Fair, create an account now:

Create a Username:
*
   6-16 letters and/or numbers. No spaces. No special characters, e.g. @#$%
Create a Password:
*
    Must contain 6-20 characters. at least 1 letter and 1 number. No spaces.
Confirm Password:
*
Note: Username and password are required to view your results. Please make a note of your Username and Password to view this year’s results and to register online in the future.

Personal Information
* Name:
  First   MI   Last
   
 *

Social Security Number:
 
 (000-00-0000)
* Birth Date:
 (mm/dd/yyyy)
* Mailing Address:
Mailing Address 2:
* City, State, Zip:
* Email:
* Confirm Email:
* Daytime Phone:
 (000-000-0000)
Alternate Phone:
 (000-000-0000)

Secret Questions
If you forget your username and/or password, you will need to answer one of these questions in order to retrieve your username/password. Please make a record of these three questions and your answers as you will need to provide the answer(s) in exactly the same format you provide now.
Question 1:
* Answer 1:
Question 2:
* Answer 2:
Question 3:
* Answer 3:

Consent & Release
I have read and consent to the Consent & Release Agreement.

I request and grant permission to Nine Health Services, Inc. and the volunteers and organizations participating in 9Health Fair to perform certain health screenings for me. I understand that my personal identifying information and test results will be confidential, with the exceptions stated below. If I choose to have blood analysis, I grant the volunteer phlebotomist permission to draw a blood sample, and I grant the contract laboratory permission to perform a set of standardized laboratory screenings on my blood sample. I understand that in order to conduct the blood analysis, 9Health Fair may disclose information from this form to the contract laboratory and that 9Health Fair will deliver the blood analysis to me. Information collected by 9Health Fair is the sole property of Nine Health Services, Inc. Recognizing the 9Health Fair is a 501(c)(3) non-profit organization, I authorize 9Health Fair to use my protected health information to contact me for fundraising purposes . In the event of an accidental needle puncture or other biohazard exposure, I authorize additional precautionary testing of the sample. I further consent and allow 9health Fair to disclose my individual results to a Colorado Regional health information exchange such as Quality Health Network or Colorado Regional Health Information Organization.

I understand that health screenings will be performed at no charge to me, except for the optional blood analysis, colon cancer screening kit, and/or any other special screenings for which a fee is charged. Third party payers will not be billed by 9Health Fair or the contract laboratory. I also understand that health screenings can provide only certain preliminary measurements, and cannot be relied upon to diagnose the existence or absence of any medical condition. I understand that my participation in 9Health Fair is not a substitute for examination by a healthcare professional/provider, and that I alone am responsible for obtaining, from a doctor or other qualified healthcare professional/provider, medical information or services concerning: (1) any aspect of my health, and (2) any information I may receive from 9Health Fair. I further understand that 9Health Fair and the contract laboratory do not guarantee the accuracy of the results of any health screenings and are not responsible for advising me concerning the results of any health screenings.

In return for being given free or low-cost health screenings, I release 9Health Fair, Nine Health Services, Inc., the contract laboratory, corporations and organizations sponsoring or participating in 9Health Fair, the owners and lessees of 9Health Fair sites, and all of their employees, officers, directors, trustees, volunteers and agents (the "Released Parties") from any and all claims, demands or assertions of liabilities which I or my representatives might make, including claims of NEGLIGENCE, arising from, or based in whole or in part on, my participation in 9Health Fair, results of 9Health Fair screenings, any statements made to me by any 9Health Fair agent, employee or volunteer, nondisclosure to me of any information, my receipt or non-receipt of any information from 9Health Fair, any event or circumstance that may occur while I am present at a 9Health Fair site, or any other act or omission of any of the Released Parties.

NOTICE TO ALL MEDICARE PART B BENEFICIARIES: I understand that should I go to my physician and/or healthcare provider, Medicare allows a screening occult blood test once every twelve (12) months; screening cholesterol, triglycerides and HDL tests once every five (5) years; Medicare allows 2 screening glucose tests per year for individuals diagnosed with pre-diabetes. Medicare allows 1 screening glucose test per year for individuals previously tested who were not diagnosed with pre-diabetes, or who have never been tested, and a screening Prostate Specific Antigen test (PSA) once every twelve (12) months for males who are over fifty (50) years of age.

MEDICARE WAIVER: I have been informed and understand fully, that NO claim will be filed on my behalf, NOR will I file a claim with Medicare or my Supplemental Insurance. I voluntarily take full financial responsibility for the screening(s) I have ordered, even if Medicare would have paid for any or all of these tests, had I gone to my physician or healthcare provider. I therefore, of my own will, refuse to authorize the laboratory or health fair provider of services to submit a claim to Medicare on my behalf.