Physician Documentation Or Medical Exception Form printable pdf download

Worksite Health Assessment

Physician Documentation or Medical Exception Form

Employee section (Please print clearly):

Employee name ______________________________________________________Gender:

Company name _________________________________________________ Location __________________________

Date of birth ________________________________________________ Priority Health Contract ID ________________

Physician name _____________________________________________ Physician phone number__________________

□ No – I have never used tobacco products

Do you use tobacco?

□ No – I used to use tobacco products

□ Yes – I currently use tobacco products

□

Physician documentation

Does not apply

The above named patient requires the following information for a company Wellness program. Testing must have been

conducted within three months of the employer group’s onsite screening date and will take the place of the patient

participating in the biometric screening portion of the Wellness program.

Date of assessment ______________

Total cholesterol _________ mg/dL

HDL cholesterol _________ mg/dL

TC/HDL ratio_________

Triglycerides ________ mg/dL

LDL cholesterol _________ mg/dL

Glucose (fasting) _________ mg/dL

Height ________ inches

Weight ________ lbs

BMI _________

Blood pressure ________/________

Waist _________ inches

Physician signature ________________________________________________ Date _________________________

□

Medical exception – pregnancy, post partum and breastfeeding

Does not apply

The above named patient requires the following information for a company Wellness program. Women who are pregnant

or have delivered within six months of the employer group’s onsite screening date or are breastfeeding will receive credit

for the biometric screening portion of the Wellness program.

□ I verify that the above named patient is under my care for pregnancy.

□ The above named patient has delivered on _________. Patient is / is not breastfeeding (Circle one)

Physician signature ________________________________________________ Date __________________________

Submit completed forms by May 31, 2014.

This form is for informational purposes only. The information contained within this form is not intended to be a substitute

for professional medical advice, diagnosis or treatment. Always seek the advice of your physician or other qualified health

provider with any questions you have regarding a medical condition. Do not disregard professional medical advice or

delay in seeking it because of something you have read on this form.

For your privacy, we recommend that you fax this form to 616-942-7283.

Please contact Priority Health Wellness at 616-464-8870 or 877-689-3161 with any questions.

Physician Documentation Or Medical Exception Form

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