IB13
Revised 04/16
State Employees’ Health Insurance Plan
Healthcare Provider Screening Form
*** This form is not to be used by a Pharmacist ***
Instructions: You are to complete Section 1 of the form and your provider is to complete Section 2. The
screening must be completed no later than October 31 and submitted to SEIB by November 15.
NOTE: Incomplete forms will not be processed. Refunds are not allowed.
SECTION 1 (To Be Completed by Participant)
Name (Please print)
Screening Date
Employee
Spouse
Retiree
Male
Age: _____________
Female
Insurance Number
Group #
Last 4 SSN #
Date of Birth
Day Time Phone Number
(00/00/00)
(
)
What best describes your race/ethnicity?
White
Black/African American
Asian
Indian or Alaska Native
Hispanic/Latino
Native Hawaiian/Pacific Islander
Other
Do you have (or have you been told you had) any of the following? (Mark all that apply.)
High Cholesterol
High Blood Pressure
Diabetes
Do you take medication for any of the following? (Mark all that apply.)
H
High Cholesterol
High Blood Pressure
Diabetes
SECTION 2 (To Be Completed by Provider) NOTE: The requested labs below are the only labs considered for
coverage if the participant is being seen for an SEIB wellness screening only.
Blood Pressure
__________ / ___________
Height _________ft. _________ in
Total Cholesterol
_______________ mg/dL
Weight
_____________________
HDL Cholesterol
_______________ mg/dL
Waist Measurement ____________
LDL Cholesterol
_________________mg/dL
Waist/Ht Ratio _________________
Triglycerides
__________________mg/dL
BMI _________________________
Blood Glucose ___________________ mg/dL
Provider’s Name:
_________________________________________________________
(Please print)
Provider Signature: _________________________________________________________________
Provider Address: __________________________________________________________________
Please return completed form to:
STATE EMPLOYEES’ INSURANCE BOARD
WELLNESS DIVISION
P O BOX 304900
MONTGOMERY AL 36130-4900
1.866.838.3059 / FAX: 334.517.9980
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