Get Hbc Incentives Qualification Form - Priority Health

This guide offers clear instructions on completing the HbC Incentives Qualification Form for Priority Health online. It is essential to provide accurate information to ensure your eligibility for the incentives program.

Follow the steps to successfully complete the form

1. Click ‘Get Form’ button to access the HbC Incentives Qualification Form and open it in your online viewer.
2. In Section 1, members need to fill out their personal information, including last name, first name, last four digits of their social security number, birth date, middle initial, contract ID number, effective date, and provide their signature and date to certify that the information is complete and accurate.
3. Section 2 must be completed by the provider. They will need to fill out the health indicators, including tobacco use status, body mass index (BMI), and blood pressure results, marking whether each criterion has been met and providing the corresponding test dates.
4. If any health indicators in Section 2 are marked 'No', proceed to Section 3. Here, additional tests such as fasting cholesterol and fasting blood sugar must be documented, indicating whether the tests were completed or ordered and the dates associated.
5. In Section 4, the provider will sign off on the qualifications, ensuring to include their Tax ID, provider group name, phone number, billing physician name, NPI number, and signature along with the date.
6. Once all sections are completed, review the form for accuracy and clarity. Users can then save changes, download, print, or share the form as needed to submit it to Priority Health.

Complete your documentation online to ensure you receive your benefits without delay.