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How do I fill this out?
To fill out this form, start by entering your personal information in Section I. Next, ensure your provider completes the necessary health measures in Section II. Finally, submit the form within the specified timeframe for valid results.
How to fill out the Health and Wellness Evaluation Form Instructions?
1
Complete the member information in Section I.
2
Visit your provider within 180 days after your effective date.
3
Ensure your provider fills Section II with health measures.
4
Sign and date the form as the member.
5
Submit the completed form within 180 days.
Who needs the Health and Wellness Evaluation Form Instructions?
1
Members applying for health rewards need this form.
2
Providers conducting health evaluations require this form.
3
Individuals undergoing preventive screenings must complete this form.
4
Parents registering children for health assessments need this form.
5
Adult patients seeking health status checks require this form.
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What are the instructions for submitting this form?
To submit the form, log in to My Account at www.carefirst.com and select HealthyBlue Rewards under the My Health section. If you prefer, fax the completed form to 800-354-8205 or mail it to Mail Administrator, P.O. Box 14116, Lexington, KY 40512-4116. Ensure you submit within 180 days for rewards eligibility.
What are the important dates for this form in 2024 and 2025?
For 2024, ensure the form is submitted within 180 days from your effective date for health rewards eligibility. Review preventive service guidelines as required annually. For 2025, confirm submission deadlines and any updates from your provider.
What is the purpose of this form?
The purpose of this form is to facilitate the health and wellness evaluation process for members. It ensures both members and providers can track health measures and screenings effectively. By completing this form, participants can earn rewards while promoting preventive care.
Tell me about this form and its components and fields line-by-line.
- 1. Member Information: To be completed by the member, including personal details.
- 2. Provider Information: To be completed by the provider, including verification and recommendations.
- 3. Health Measures: Sections for recording vital health statistics and screening results.
What happens if I fail to submit this form?
Failing to submit this form may result in ineligibility for Healthy Rewards. Members must complete and submit the form on time to receive the associated benefits. Late submissions will disqualify rewards despite completing the health measures.
- Lost Rewards: Missing the deadline means you will not receive potential benefits.
- Incomplete Assessments: Not submitting may leave health tracking incomplete.
How do I know when to use this form?
- 1. Preventive Health Check: Use this form for routine health evaluations.
- 2. Eligibility for Rewards: Eligible members must fill this out to receive rewards.
Frequently Asked Questions
How can I edit this PDF?
You can edit this PDF by clicking the edit button and modifying text fields.
Can I sign the PDF electronically?
Yes, you can add your electronic signature using the signature tool.
How do I share this PDF with others?
Use the sharing options to send the PDF link to others.
Is there a limit to how many times I can edit?
You can edit the PDF as many times as you need before downloading.
What is the purpose of this form?
The form is designed for members and providers to assess health measures.
How do I know if my submission is successful?
Check for confirmation notifications after submission.
Are there any fees associated with this form?
No, this form submission is free of charge.
Who should fill out the member information?
The member must fill out their personal information in Section I.
What happens if I miss the submission deadline?
Late submissions may disqualify you from receiving rewards.
Where can I find additional information?
Visit the CareFirst website for more health plan details.
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