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How do I fill this out?
To fill out this form, start by providing your personal details clearly in black ink. Make sure to complete all sections accurately, particularly the health conditions and medications you are currently taking. Finally, ensure your healthcare provider signs the form before submission.
How to fill out the Public Education Employees Health Screening Form?
1
Print your details legibly in black ink.
2
Complete all relevant sections regarding your health.
3
Provide your healthcare provider's information accurately.
4
Sign the form to affirm the provided information.
5
Submit the form to the appropriate address or fax.
Who needs the Public Education Employees Health Screening Form?
1
Active and retired public education employees need this form to participate in the wellness program.
2
Spouses of eligible employees need the form to assess their health risks.
3
Healthcare providers need it to record the patient's health information.
4
Insurance departments require it to process claims without copayments.
5
Employees aiming for preventive health checkups benefit from this screening form.
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What are the instructions for submitting this form?
Submit this completed form to the ADPH Wellness Program at 201 Monroe Street, Suite 986, Montgomery, AL 36104. You can also fax the form to 334.206.0385 or 334.206.0394. Ensure all sections are filled out properly to avoid processing delays.
What are the important dates for this form in 2024 and 2025?
For 2024, ensure to complete your screenings by the end of June. In 2025, new guidelines may be released by mid-year, so stay updated for any changes.
What is the purpose of this form?
The purpose of this form is to gather essential health information from public education employees and their spouses. It serves as a prerequisite for participation in the ADPH Wellness Program, aimed at promoting better health outcomes. By completing this form, individuals can receive needed screenings and referrals based on their health assessments.
Tell me about this form and its components and fields line-by-line.
- 1. PEEHIP PID: Personal Identification number required for the program.
- 2. Patient SSN: Social Security Number needed for verification.
- 3. Sex: Indicates whether the participant is male or female.
- 4. Screening Date: Date when the health screening is completed.
- 5. Birth Date: Participant's date of birth.
- 6. Zip Code: Participant's residential zip code.
- 7. Last Name: Surname of the participant.
- 8. First Name: First name of the participant.
- 9. Middle Initial: Middle initial of the participant.
- 10. Health Conditions: List of specified health conditions the participant may have.
- 11. Medications: List of medications taken for health conditions.
What happens if I fail to submit this form?
Failing to submit this form may result in not receiving the wellness program's benefits and support. You could miss out on important screenings and health assessments necessary for maintaining good health. Timely submissions ensure you remain compliant with program requirements.
- Loss of Benefits: Without submission, participants could lose access to health screenings and incentives.
- Delayed Health Assessments: Health assessments may be delayed, impacting timely care.
- Ineligibility for Program Participation: Non-submission could lead to ineligibility for participation in the wellness program.
How do I know when to use this form?
- 1. Participation in Wellness Programs: Used to enroll in health screenings offered by the program.
- 2. Claiming Preventive Services: Required for insurance claims related to preventive visits.
- 3. Health Risk Assessments: Utilized to evaluate personal health risks.
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