Health Provider Screening Form for PEEHIP Healthcare
This file contains the Health Provider Screening Form for PEEHIP public education employees and spouses. It includes instructions on how to fill out the form for wellness program participation. The form collects personal, medical, and screening details to assess wellness.
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How do I fill this out?
To fill out this form, follow the section-by-section instructions. Complete all necessary personal and medical details accurately. Ensure the healthcare provider section is filled and signed accordingly.
How to fill out the Health Provider Screening Form for PEEHIP Healthcare?
1
Read and understand the Notice Regarding Wellness Program.
2
Fill out the personal information section with your details.
3
Answer questions about your tobacco usage and medical history.
4
Have your healthcare provider complete the medical screening section.
5
Submit the form to the ADPH Wellness Program by fax or mail.
Who needs the Health Provider Screening Form for PEEHIP Healthcare?
1
Active employees participating in PEEHIP's healthcare plan for annual wellness screening.
2
Retired employees who are part of PEEHIP and need to submit their wellness data.
3
Spouses enrolled in PEEHIP’s healthcare plan seeking wellness program benefits.
4
Individuals aiming to identify risks for high blood pressure, cholesterol, or diabetes.
5
Participants looking to get a premium waiver for completing wellness screenings.
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1
Upload your PEEHIP Health Provider Screening Form on PrintFriendly.
2
Edit the personal information section with accurate details.
3
Answer all medical history and tobacco usage questions.
4
Have your healthcare provider fill out the medical screening section.
5
Save and submit the edited form digitally.
What are the instructions for submitting this form?
To submit this form, ensure all sections are accurately completed and signed by both you and your healthcare provider. The completed form can be submitted via fax to 334.206.0385 or 334.206.0394, or mailed to ADPH Wellness Program, 201 Monroe Street, Suite 986, Montgomery, AL 36104. It is advisable to submit the form well before the August 31 deadline to ensure timely processing and avoid any delays in receiving wellness program benefits.
What are the important dates for this form in 2024 and 2025?
Important dates for this form in 2024 and 2025 include the annual deadline of August 31 for wellness screening participation to receive premium waivers. Ensure form submission well before the deadline for timely processing.
What is the purpose of this form?
The purpose of this form is to participate in the PEEHIP wellness program by documenting personal and medical information required for wellness screenings. This helps identify potential health risks such as high blood pressure, obesity, high cholesterol, or diabetes. The form facilitates the completion of the wellness program requirements, enabling participants to qualify for premium waivers and other health incentives.
Tell me about this form and its components and fields line-by-line.
- 1. Participant Information: Includes PEEHIP PID, Patient SSN, gender, screen date, birth date, zip code, last name, first name, and middle initial.
- 2. Tobacco Use: Questions about tobacco or electronic smoking device usage in the last 12 months.
- 3. Race/Ethnicity: Multiple-choice options for race/ethnicity identification.
- 4. Medical History: Questions regarding high cholesterol, high blood pressure, and diabetes.
- 5. Medication Usage: Information on medication intake for cholesterol, blood pressure, and diabetes.
- 6. Provider Screening: Healthcare provider completes blood pressure, blood glucose, cholesterol, height, weight, and BMI information.
- 7. Claims Filing Instructions: Instructions for copayment waiver and how to file claims for office visits.
- 8. Healthcare Provider Information: Provider's name, signature, type, and contact details.
- 9. Submission Instructions: Directions for form submission via fax or mail to the ADPH Wellness Program.
What happens if I fail to submit this form?
Failure to submit this form may result in losing eligibility for wellness program benefits and premium waivers.
- Missed Benefits: Ineligibility for wellness program incentives and premium waivers.
- Health Risk: Failure to identify potential health risks such as high blood pressure or diabetes.
- Increased Costs: Higher out-of-pocket expenses due to lack of premium waivers.
How do I know when to use this form?
- 1. Annual Screening: Complete the form annually for wellness screening participation.
- 2. Premium Waivers: Submit the form to qualify for wellness premium waivers.
- 3. Risk Assessment: Identify and manage potential health risks through screenings.
- 4. Tobacco Usage: Document tobacco usage status for additional incentives.
- 5. Healthcare Provider Validation: Ensure healthcare provider completes their section to validate the screening.
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