Get Physician Fax Screening Consent Form - Empireblue

Filling out the Physician Fax Screening Consent Form - EmpireBlue is essential for participating in health screening programs. This guide will assist you through the steps to complete the form accurately and effectively online.

Follow the steps to complete the form accurately

1. Press the ‘Get Form’ button to obtain the document and open it for editing.
2. Begin by entering your Member ID, which can be found on your health care ID card. Ensure this is formatted as 99999999 and begins with an 8.
3. Indicate whether you are fasting by selecting 'Yes' or 'No.' Note that fasting is recommended for more accurate readings.
4. Authorize the medical health care provider by entering their name, address, and contact details in the provided fields.
5. Have your health care provider complete the required biometric data fields, including height, weight, total cholesterol, HDL, LDL, triglycerides, glucose, and blood pressure.
6. Ensure that your health care provider signs and dates the form in the designated areas.
7. Submit the completed form by faxing it to 866-698-9924 or by mailing it to 5068 West Plano Parkway, Suite 290, Plano, TX 75093 USA. Remember to write 'golub' in the lower left corner of the envelope.
8. Once you have submitted the form, keep a copy for your records. This helps ensure you have proof of submission.

Complete the Physician Fax Screening Consent Form - EmpireBlue online today to participate in your health screening program.