Download Instructions for Receiving Your Biometric Screening With Your

Instructions for Receiving Your Biometric Screening
With Your Personal Physician
We are pleased that you are participating in the health screenings this year. Participation in the biometric screening is
confidential. Please review these instructions to ensure that your information is complete and sent to the correct
location.
Submitting your Biometric Screening Results:
1. If you have already completed a biometric screening through your physician or medical provider on or after
September 1, 2014:
a. Fill out the participant information section below and leave both pages of this form with your provider. Ask
them to complete the biometric data portion and fax the completed form to the number below
NO LATER THAN August 15, 2015. Your provider can also complete the form and return it to you to fax.
2. If you choose to complete your biometric screening through your physician or medical provider:
a. Schedule an appointment with your provider before August 15, 2015. Tell them that you need a lipid panel,
blood glucose or A1C, height, weight, waist circumference and blood pressure for your company wellness
program and to code the visit as preventive care.
b. Fill out the participant information section below and leave both pages of this form with your physician. Ask
them to complete the biometric data portion and fax the completed form to the number below NO LATER
THAN August 15, 2015. Your provider can also complete the form and return it to you to fax.
Wellness Corporate Solutions
Attn: Information Management
SECURE FAX: 866-889-5180
Participants may complete either A1C or glucose testing, but needn’t complete both in order to earn credit.
ALL RESULTS MUST BE ENTERED INTO THE APPROPRIATE BOXES ON PAGE 2 OF THIS FORM. SEPARATE FORMS
CANNOT BE REVIEWED OR PROCESSED.
PARTICIPANT CONSENT
Participants must read consent language below and sign the consent statement on page 2 of this document.
I understand that the purpose of my health screening is to evaluate my health status and any potential health risks and I consent to participate in my employer’s
Wellness Program requiring me to obtain the information requested below. I hereby request and have authorized my physician to provide this information to Wellness
Corporate Solutions, LLC who will in turn transmit them to Accountable Health Solutions who may provide follow-up services in connection with screening data. My
authorization shall be effective for one year from the date of signing however, I may revoke it sooner by notifying my physician. However, the revocation will not apply
to information provided prior to the date I notify my physician. I understand that Wellness Corporate Solutions, LLC and Accountable Health Solutions are not
responsible for diagnosing, treating, or preventing any medical disease or condition that I currently have or may have in the future. I also understand that Wellness
Corporate Solutions, LLC or Accountable Health Solutions will not give me medical advice and that I must seek such advice from my own physician. Wellness Corporate
Solutions, LLC and Accountable Health Solutions have agreed with your employer that they will not use or disclose your health information except as permitted or
required by HIPAA and their applicable Business Associate Agreements. Finally, I understand that I may faint, bruise, or have other effects as a result of my blood being
drawn. I voluntarily agree and consent to participate in the health screening and accept and assume all risks associated with such participation. I hereby release and
forever discharge Wellness Corporate Solutions, LLC and Accountable Health Solutions, including their owners, employees, and agents from any and all claims,
demands, actions, and damages, including attorney’s fees and costs, arising out of or in any way related to my participation in the health screening or Wellness
Program.
If you have any questions please contact Accountable Health Solutions at 877-475-3442.
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DATA FORM FOR HEALTH SCREENING WITH YOUR
PERSONAL PHYSICIAN
3711
PARTICIPANT: Complete participant information, bring form to provider for completion.
Retain a signed copy for your records.
PROVIDER: Complete Measurements section and sign the form.
FAX completed form to Wellness Corporate Solutions at 866-889-5180 by August 15, 2015
CHILDRENS OF WISCONSIN
PARTICIPANT INFORMATION: TO BE COMPLETED BY THE PARTICIPANT. PLEASE WRITE NEATLY. ONE CHARACTER PER BOX
FIRST NAME
LAST NAME
DATE OF BIRTH (MM/DD/YYYY)
/
M
M
/
D
D
Y
Male
GENDER:
Female
EMAIL ADDRESS
Y
Y
ZIP CODE
Y
Employee
Spouse/Dependant
RELATIONSHIP:
IMPORTANT: PLEASE READ BELOW - Health Coaching Consent - Accountable Health Solutions
PREFERRED PHONE
YES! Please enroll me in the Health Coaching
program offered by my employer through Accountable
Health Solutions. If I qualify, contact me to get started. I
understand that my eligibility for the Health Coaching
program is determined by the results of my screening
(and Wellness Assessment, if applicable).
WORK
HOME
MOBILE
During what time frame would you prefer to have your first 15 minute
Health Coaching phone call?
-
-
(We will use the preferred phone number you have provided above.)
I am not sure. Please contact me to discuss my options
8:00am - 9:00am
3:00pm - 6:00pm
for Health Coaching, offered by my employer, at no cost
9:00am - 12:00pm
6:00pm - 8:00pm
to me. I understand that I can enroll in the program in the
12:00pm
3:00pm
8:00pm - 9:00pm
future as long as I meet the eligibility conditions
Would
you
prefer
a
Spanish-speaking
Health Coach?
determined by my employer.
PARTICIPANT
SIGNATURE
No
Yes
I, the above named participant, have read, understand and agree to the participant
consent printed on page1 of this form. No attempts to modify or amend this form will
change such terms or in any way be binding upon Wellness Corporate Solutions.
(REQUIRED)
BODY MEASUREMENTS & BIOMETRIC RESULTS (TO BE COMPLETED BY PHYSICIAN)
SCREENING DATE
/
/
FASTING STATUS:
Yes
BLOOD TEST RESULTS
BODY COMPOSITION & BLOOD PRESSURE
HEIGHT (without shoes)
.
ft.
.
WEIGHT (without shoes)
WAIST
BLOOD PRESSURE
TOTAL CHOLESTEROL
mg/dL
HDL CHOLESTEROL
mg/dL
kg/m
LDL CHOLESTEROL
mg/dL
Inches
TRIGLYCERIDES
mg/dL
GLUCOSE
or
A1C
mg/dL
in..
Pounds
.
.
BMI
No
2
/
mmHg
NOTES:
.
%
ALL RESULTS MUST BE ENTERED INTO THE APPROPRIATE BOXES ON THIS PAGE. SEPARATE FORMS CANNOT BE REVIEWED OR PROCESSED.
-
-
PHONE NUMBER (Provider/Clinic)
PHYSICIAN SIGNATURE (REQUIRED)
PLEASE FAX COMPLETED DATA FORM TO: WELLNESS CORPORATE SOLUTIONS, SECURE FAX: 866-889-5180
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