Physician Verification Form

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BLUE CROSS BLUE SHIELD OF MICHIGAN
PHYSICIAN VERIFICATION FORM
Provider Instructions: Please complete and sign this form. FAX the completed form to Blue Cross Blue Shield of
Michigan Engagement Center 1-877-885-2596. Do not forward the form through Provider Secured Services.
PATIENT INFORMATION
Patient’s last name:
Patient’s first name:
Age:
Gender:
Birth date:
 M
 F
/
/
Street address:
Home phone no.:
(
)
City:
State:
ZIP Code:
Contract ID/Enrollee Number:
Group Number:
Employer:
MEDICAL WAIVER
If your patient is unable to meet their clinical criteria or physical activity requirements, check the appropriate value(s)
below. By signing this form you verify that it is medically inadvisable or unreasonable for the patient to achieve the
criteria or participate in the physical activity requirement.
 A1c
 Fasting blood sugar
 BMI
 Non-tobacco user
 Blood pressure
 Walk a required number of daily steps
 Cholesterol
 Waist circumference
Medical Waiver Reason (check the appropriate reason):
 Patient in hospice (waive all requirements)
 Patient is pregnant (waive BMI, waist circumference, blood pressure, cholesterol, and blood sugar only)
 Patient has muscular build (waive BMI only)
 Other (provide reason in the space below):
Reason:
HEALTH MEASURE ACHIEVED
When the Qualification Form was completed or a worksite screening conducted, my patient did not meet their health
measure value. They now meet their requirement(s) as documented below:
 BMI value _______
 Blood pressure value ____ /____
 Blood sugar (FBS) value _______
 Blood sugar (A1c) value _______%
 Cholesterol value _______
 Non-tobacco user (based on a new continine test) _____________ ng/mL
 Waist circumference value _______
Date of evaluation: ____________
PHYSICIAN INFORMATION
Physician last name:
Physician first name:
NPI:
Physician signature:
Date:
Phone number:
(
)

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