Optima Health

HEAL Program
Classes held online only.

November 22 - January 10
Tuesdays from 1:00 p.m. to 2:30 p.m.

Instructions:

1. Complete the registration form below.
2. We will send a confirmation email.
3. The email will include a link to join online and a phone number if you prefer to listen only.
4. If you do not receive the confirmation email within an hour, please check your spam folder. If it is not there, please call 1-833-261-2367.

Please register before 11:59 PM EST on Thursday, November 10, 2022.

Please submit the registration form when complete.

Weekly Topics Include:

Healthy Eating
Medicine
Emergencies
Appointments
Preventing Diseases
It’s My Health
Review
“Feel” Trip

First Name *

Last Name *

Phone Number *

Email Address *

Street Address *

City *

State *

Zip Code *

Age

English as a Second Language *

Are you an Optima Health member? *

How did you hear about the HEAL Program?

Highest Level of Education

I accept the Terms of Use *

I DO consent to the use of my name (or family member’s) by Sentara Health and/or Optima Health Plan in connection with the use of my image as noted below.

Electronic Signature

Date: April 26, 2024

I DO NOT consent to the use of my name (or family member’s) by Sentara Health and/or Optima Health Plan in connection with the use of my image as noted below.

Consent for Photography/Videotaping/Interview
(For Media, Public Relations, Marketing, and Educational Purposes)

Instructions:

Check the box for either “I do” or “I do not” consent to use your name.
Type your name in the signature box and date to complete.

I consent to the use of interviews, photographs, or videos of me or my family member(s), including images and information that may disclose my protected health information, for use, reproduction, and/or publication by Sentara Health and/or Optima Health Plan ("Sentara"), and authorize release and use by Sentara to other organizations or news outlets, including local, regional, national, and international print, broadcast, and internet media and other electronic media.

I understand and agree that my name and these images and interviews, including me or my family member’s name, image, likeness, and/or voice, may be used by news media or by Sentara for purposes of education, promotion, public relations, and/or marketing, and that they may appear in print, on television, in radio broadcasts, the internet or text messages. I understand that there is a possibility that I may be identifiable in these photographs, videos, or written/audio accounts, though my name will not be published unless I specifically agree below.

I agree to release and hold harmless Sentara, its trustees, agents, officers, and employees from any and all liability which may arise from the making of or use of these photographs, videos, or interviews, and, if specified, use of my name, and I will not request payment for the use of my image, likeness, or name. I hereby waive and release Sentara, its Trustees, officers and employees from liability for any claim that I or my family member may have based on rights of privacy, publicity, defamation, copyright or trademark infringement, disclosure of protected health information, or any other right based on Sentara’s use of any image, recording of me or my name.

I understand that signing this authorization is strictly voluntary and that I may revoke it at any time. However, I acknowledge that any interviews or images to which I consented prior to revocation may already be in the public domain and not retrievable. I also understand that any protected health information released by me under this consent will no longer be protected by federal or state privacy laws.

Terms of Use for Virtual Meeting Participation
Optima Health utilizes a virtual meeting platform (owned and operated by a third-party) known as WebEx to conduct virtual meetings. When you access an Optima Health meeting by clicking on the WebEx link provided to you by Optima Health you are agreeing to these terms of use. If you do not agree to these terms of use below please do not utilize the WebEx link provided to you by Optima Health. By clicking on the WebEx link you acknowledge that the virtual meeting platform used by Optima Health is not a secure platform and anyone who obtains a link from Optima Health can access it as well as share access with others. You acknowledge and agree that Optima Health cannot guarantee your privacy when you attend a virtual meeting organized by Optima Health; if you share personal information it could be used and/or recorded by third parties without your consent. When accessing an Optima Health virtual meeting you agree not to record the meeting and not to copy or use the images of those participating in the virtual meeting in any manner. You acknowledge and agree that your participation in the virtual meeting is at the invitation of Optima Health, and Optima Health is permitted to terminate your participation in its sole discretion if it deems your participation in the meeting harmful to meeting participants, disruptive, or otherwise unacceptable, in Optima Health’s sole discretion. You agree not to use the virtual meeting to solicit meeting participants or to interact with participants during or after the meeting in an offensive, threatening or illegal manner. You acknowledge and agree that Optima Health may share your name with governmental authorities if Optima Health reasonably believes your actions threaten a third party or are unlawful. You agree not to allow a minor to participate in a virtual meeting unless you are the parent or legal guardian of the minor, and you will monitor the actions of such minor at all times to ensure compliance with these terms of use. By participating in the Optima Health virtual meeting you agree to hold harmless, release, and forever discharge Optima Health, its officers, directors, employees, agents, and affiliated companies, from all claims, demands, and causes of action which you may have by reason of participation in the Optima Health virtual meeting.

Optima Health Medicaid is a managed care organization contracted with the Virginia Department of Medical Assistance Services (DMAS). Enrollment is dependent on Virginia DMAS eligibility. Optima Health complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

Optima Health Presents - The HEAL Program (Health Education and Literacy)