2021 WESTERN LEGISLATIVE ACADEMY

COVID – 19 HEALTH SCREENING

The Council of State Governments West (CSG West) is excited to welcome you to the 2021 Western Legislative Academy in Colorado Springs. We are Heed Health and are pleased to partner CSG West to provide a healthy start to the meeting.

Please use this HIPAA compliant page to provide the required pre-event COVID-19 registration information no later than Friday, December 3rd.

On Tuesday, December 7th please visit the Heed Health testing area to complete your required on site screening.

 

2021 Western Legislative Academy Health Screening Registration Form

Event Information:

Your Name
MM slash DD slash YYYY
Each individual’s test results can only be attributed to a single email. If you are registering multiple individuals, you will have to use a separate email for each.
Home Address

Your Information:

Please click HERE to open and review the HIPAA & Consent Form.

Note: You do not need to print and sign the actual HIPAA forms linked above, signing below is your attestation that you reviewed and agree to the document.

ACKNOWLEDGEMENT OF RECEIPT OF HIPAA NOTICE OF PRIVACY PRACTICES By signing below, I acknowledge that I have been provided a copy of Heed’s Notice of Privacy Practices and have therefore been advised of how health information about me may be used and disclosed by Heed and how I may obtain access to and control this information. *