Download Doctor Verification form

yes no Was this document useful for you?
   Thank you for your participation!

* Your assessment is very important for improving the work of artificial intelligence, which forms the content of this project

2017 Spring Know Your Numbers
Provider Verification Form
Mission: The CSI Wellness Program is dedicated to improving the health and well-being of employees through health
education and activities that support positive lifestyle choices, thereby resulting in improved employee morale, productivity
and healthcare cost savings for the college. (Rev: 9/2014)
Participant Information
_____________________ *Employee ID #: ______________________
Gender:  Male  Female
Date of Birth:
___ *Personal phone #: _____________________
CSI Department: _______________________ Location: _____________________ *Employee email:
I would like to be contacted to discuss my health measurements by a Healthy U Coach.  Yes
Employee signature:
 No
Health Care Provider Directions
As the healthcare provider for a CSI employee, we would like to work collaboratively with you to support him or her in achieving the CSI
Health Initiative targets. If you have any questions about the program, please contact St. Luke’s at (208) 814-9182.
Please complete ALL the biometric measures or alternative standards below. Use examination and lab results that are considered
current for this employee. Please provide a copy to your patient to submit toward a participation incentive through CSI.
Biometric Health Targets
Provider Alternative Standards
If the CSI Health target is medically inadvisable or unreasonably difficult to achieve, a
reasonable alternative standard or provider adjusted target.
No tobacco use
A reasonable alternative is completion of a recognized tobacco or nicotine cessation
program or medications, plus establishing a quit date to stop.
BMI: less than 35 -ORWeight
Blood Sugar
Waist Circumference:
Women less than 35 in.
Men less than 40 inches
Systolic: less than 140
Diastolic: less than 90
A reasonable alternative is achieving a 2.5% weight reduction at midterms, followed by
an additional 2.5% weight reduction by year end for a 5% total weight reduction, or a
provider adjusted weight loss target, within 1 year.
A reasonable alternative is a provider adjusted blood pressure target.
Fasting Blood Glucose
(FBG): less than 100
-OR- A1c: less than 5.7
A reasonable alternative is a provider adjusted FBG or A1c target.
-OR- A1c: less than 8.0%
Health Care Provider Verification
I agree that all the requested measurements have been discussed and I have reviewed the outcomes with my patient.
Provider Name: (PRINT) _______________________________________
Phone #: ___________________________
Clinic Name: ____________________________________________________________
Fax#: ______________________________
Provider Signature:
Date: ______________________________
Deadline for submission to St. Luke’s: on or before September 15, 2017
Scan & email form to: or Drop off at: St. Luke’s Wellness Office 496 Shoup Ave. Suite A. Twin Falls, ID 83301