Health Risk Assessment (Page 5 of 5) in pdf

Health Risk Assessment Page 5

First Name, Middle Name, Last Name, and Suffix

mihealth Card Number

Healthy Behaviors -

Choose one of the following statements (

)

Patient does not have health risk behaviors that need to be addressed at this time.

Patient has identified at least one behavior to address over the next year to improve their health

(choose one or more below):

Increase physical activity, learn more about nutrition and improve diet, and/or weight loss

Reduce/quit tobacco use

Annual influenza vaccine

Agrees to follow-up appointment for screening or management (if necessary) of hypertension,

cholesterol and/or diabetes

Reduce/quit alcohol consumption

Treatment for Substance Use Disorder

Other: explain

Patient has a serious medical, behavioral or social condition(s) which precludes addressing unhealthy behaviors at

this time.

Unhealthy behaviors have been identified, patient’s readiness to change has been assessed, and patient is not ready

to make changes at this time.

Primary Care Provider Attestation

I certify that I have examined the patient named above and the information is complete and accurate to the best of my

knowledge. I have provided a copy of this Health Risk Assessment to the member listed above.

Print Name (First Name, Last Name)

National Provider Identifier (NPI)

Signature

Date

Submission Instructions:

•

Submit completed forms in the secure manner specified by the member's Managed Care Plan.

Authority:

MCL 400.105(d)(1)(e)

Michigan Department of Community Health is an equal

opportunity employer.

Completion:

Of this form provides information to better meet the health needs of

Healthy Michigan Plan beneficiaries in Managed Care Plans.

DCH-1315 (03/14)

Page 5 of 5

Health Risk Assessment Page 5