Physician Screening Form

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Physician Screening Form
STATE OF WISCONSIN
SECTION I: TO BE COMPLETED BY YOU (PLEASE PRINT)
Name: _____________________________________________ Employee ID #: _________________ Gender: M/F
Address: __________________________________________________________________________________________
City: _____________________________________________________ State: ___________ Zip: _________________
Work Phone Number: (
) ___________________________
DOB: _________________________________________
Email:_______________________________________________
Tobacco Use:
(
) Yes
(
) No
I, the undersigned understand that my employer is the Plan Sponsor of my Group Health Plan and may receive information regarding my
participation in this health screening for administrative purposes, including but not limited to, billing and attendance. I understand that
my Group Health Plan may be administered and/or insured by my Employer or an insurance company such as HealthPartners, one of
these entities or their selected vendor may have access to my individually identifiable information for condition management purposes,
or to appropriately operate or administer my Group Health Plan. The organizations involved in this activity recognize the importance of
safeguarding individually identifiable health information and are obligated to take reasonable steps to protect such information. I
understand that labs conducted outside of the federal guidelines for preventive services or for diagnostic purposes other than
participation in the Well Wisconsin program may be subject to deductibles and coinsurance.
Signature: ______________________________________________
Date: ____________________________
SECTION II: TO BE COMPLETED BY YOUR CLINICIAN
Examination and Blood Work Date: _________________________________________
Height: ________feet ___________inches
Weight: ____________pounds
Waist Circumference: __________inches
Total Cholesterol: ____________mg/dl
HDL: _____________
Ratio Total/HDL: ______________
Glucose Level: _______________ mg/dl
Triglycerides: _____________ LDL Cholesterol: _______________
Blood Pressure: _________ / _________ mm/Hg
A1c (optional):__________________
Clinician’s Signature: ________________________________________________________________
Clinician’s Name (please print): ________________________________________________________
Clinician’s Address:
_____________________________
_____
_____________________________ _
Physicals and blood work must be completed between January 1, 2016 and December 28, 2016
Return this form by: e-mail () or fax (410-356-6205)
SUBMIT YOUR RESULTS on or before December 28, 2016
THIS FORM MUST BE COMPLETED TO RECEIVE YOUR REWARD

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