Health Risk Assessment printable pdf download

Health Risk Assessment

INSTRUCTIONS

The Healthy Michigan Plan is very interested in helping you get healthy and stay healthy. We want to ask

you a few questions about your current health and encourage you to see your doctor for a check-up as

soon as possible after you enroll with a health plan, and at least once a year after that. Take this form

with you when you go. An annual check-up appointment is a covered benefit of the Healthy Michigan

Plan and your health plan can help you with a ride to and from this appointment. Your doctor and your

health plan will use this information to better meet your health needs. The information you provide in this

form is personal health information protected by federal and state law and will be kept confidential. It

CANNOT be used to deny health care coverage.

If you need assistance with completing this form, contact your health plan. You can also call the

Beneficiary Help Line at 1-800-642-3195 or TTY 1-866-501-5656 if you have questions.

Instructions for completing this Health Risk Assessment for Healthy Michigan Plan:

•

Answer the questions in sections 1-3 as best you can. You are not required to answer all of the

questions.

•

Call your doctor’s office to schedule an annual check-up appointment. Take this form with you to your

appointment.

•

Your doctor or other primary care provider will complete section 4. He or she will send your results to

your health plan.

After your appointment, keep a copy or printout of this form that has your doctor’s signature on it. This is your

record that you completed your annual Health Risk Assessment.

DCH-1315 (03/14)

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Health Risk Assessment