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Primed for Life Points Submission Form

Points submission form for our Primed for Life Program. Drivers must submit this form to get points for DHF and the CDWP each quarter. The form must be submitted prior to the end of each quarter to receive credit for each session completed. Only one session can be submitted for each Points Submission Form.

HIPAA Privacy Authorization Form
HIPAA Disclaimer for Primed for Life Program **Authorization for Use or Disclosure of Protected Health Information (Required by the Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164) **
I authorize Prime, Inc. to use and disclose the protected health information described below for the Prime Driver Health and Fitness (DHF) program. This authorization for release of information covers the period from the start of my association at Prime until my termination of association with Prime.
I authorize the release of my participation in the Primed for Life Program. Info released includes all fields below including; Name (first, last), driver code, phone, email, and verification that you participated in Primed for Life.
This information may be used for consultation, reporting and promotion, or other purposes. I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization. I understand that my eligibility for benefits will not be conditioned on whether I sign this authorization. I understand that information may be disclosed by the recipient and may no longer be protected by federal or state law.
Name*
First Last
Driver Code*
Are you in the CDWP?
- Yes
- No
Phone*
Email*
I verify that I completed a "Primed for Life" counseling session with our Good Dads counselors.*
- YES, I verify I completed a Primed for Life counseling session
- NO, I did not complete a Primed for Life counseling session
Which Primed for Life session did you complete?*
Great work! You just earned 5 points towards your DHF and CDWP quarterly points totals by completing a Primed for Life Discovery Call!
Great work! You just earned 50 points towards your DHF and CDWP quarterly points totals by completing your Primed for Life assessment.
Great work! You just earned 40 points towards your DHF and CDWP quarterly points totals by completing a Primed for Life session.
How would you rate your Prime for Life counseling session?*
ExcellentPretty goodNeutralNot so greatTerrible
I would recommend this Primed for Life counseling service to other drivers like myself?*
Strongly disagree Disagree Neutral Agree Strongly agree
Do you have any personal successes from your Primed for Life counseling sessions you'd like to share?*
- Yes
- No
What successes would you like to share?*
Can we highlight your successes through a Driver Spotlight on our website?*
- Yes
- No
Do you have any feedback on how we could improve future Primed for Life counseling experiences?*

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Last Name*

Email*

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This field is for validation purposes and should be left unchanged.

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