U Got This Program Enrollment Form

Print – Fill Out Completely

Thank you for your interest in U Got This. Sponsored by Abbott, this program is offered by the American Diabetes Association's National Center for Urban Solutions (NCUS). You agree to participate in the program by completing this form. More information is available at www.ugotthiscolumbus.com.

First Name *

Last Name *

Address *

City/State *

Date of Birth *

Email Address *

Zip *

Phone Number *

Gender *

Male

Female

Other

Race *

Ethnicity *

Non-Hispanic

Hispanic

Please complete the following information to confirm eligibility for program participation.

Have you been diagnosed with diabetes? *

Diabetes Type: *

If yes: Do you use insulin? *

If yes: Do you use a Continuous Glucose Monitor (CGM) device? (Please select from options 1-5) *

Do you qualify for one or more of the following programs? (Please select all that apply) *

Medicaid

Free and reduced lunch

Special Supplemental Program for Women, Infants, and Children (WIC

Supplemental Nutrition Assistance Program (SNAP)

None of the above

Were you referred to this program by a physician? *

[if yes] physician name: *

[if yes] physician email address: *

[if yes] physician phone number: *

Please read and initial after each section.

Program Communications The program will include multiple opportunities for sharing your experience with a CGM. I hereby consent to speaking with the Program Communications Team and to participating in focus groups and interviews. *

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Photo and Video Release I hereby grant National Center for Urban Solutions, the American Diabetes Association, and Abbott permission to use my likeness in a photograph, video, or other digital media (“photo”) in any and all of its publications, including web-based publications, without payment or other consideration. *

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Consent for Program Participation I hereby agree to consent to participate in U Got This. I understand that the information gathered is a part of the screening process. If I have any questions, I understand that I have the opportunity to discuss any and all of my medical concerns with regard to the health screening program with a healthcare provider. I acknowledge I have been apprised of any risks of the health screening program and am voluntarily electing to participate. I agree to hold harmless ALL the National Center for Urban Solutions (NCUS) representatives, and its affiliates, as well as their health care workers, employees, agents, physicians, volunteers and sponsors. Your information will not be shared with third parties without your consent. I hereby grant permission to the staff and volunteers of NCUS’s agencies/agents to obtain a blood sample to perform a screening test for diabetes. I understand this test does not diagnose diabetes. I understand NCUS will follow up with me if my results are abnormal. I hereby release all rights and claims for damages against NCUS and its agencies/agents resulting from this test. I am at least 18 years of age. *

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ADA Disclosure Statements

I understand the following terms and conditions of the program.

The information I provided regarding my annual income and eligibility for the programs listed above is accurate and complete.
The program covers the costs for the CGM device and CGM supplies necessary to use the device for 9 months (trial period). Following the trial period, I am under no obligation to continue using the CGM device. If I choose to continue using the CGM device, I am under no obligation to obtain CGM supplies from any particular supplier.

I agree not to sell or seek reimbursement from any payer or provider for any program-provided items

Signature *

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Date * +

To be completed by NCUS Wellness Coach:

Participant’s Primary Care Provider: Name

Medical Center (if any association)

Phone

Email

Are they willing to participate in pilot?

[If participant doesn’t have primary care provider] Pilot PCP Assigned

[If participant’s PCP won’t participate in pilot] Is participant willing to see one of the Pilot PCP’s?

American Diabetes Association®’s Health Equity Now™ platform is sponsored by Abbott. All trademarks are the property of their respective owners