What is the Diabetes Prevention Program?
The Diabetes Prevention Program (DPP) offers support and education on healthy habits to help prevent diabetes.

What is the purpose of this form?
This consent form is asking if you agree to having certain information collected while participating in the program. As a part of DPP, we need to collect some patient data. This data is reported to the Center for Disease Control (CDC) so that we can continue to offer and improve our program.

How will information be collected?
We will be collecting information through the Wellocity app.

What information will be collected?
As a part of this program, we will collect information on your:

• Demographics (such as your age and/or gender)
• Blood sugar labs
• Physical activity (exercise)
• Height and weight

1. Only information related to the DPP program will be collected and saved. My information will only be shared with the entities (organizations) listed on this form. My information will not be shared with anyone else.

2. I will be given a specific number. My name will not be included in the data reported to the above entities.

3. My information will be protected under the Health Insurance Portability and Accountability Act (HIPAA).

4. I can remove my consent in writing at any time.