Get Wellness Evaluation Form

Completing the Wellness Evaluation Form online is a crucial step in managing your health and wellness. This guide will provide you with clear, step-by-step instructions to help you fill out the form accurately and efficiently.

Follow the steps to complete your Wellness Evaluation Form successfully

1. Press the ‘Get Form’ button to access the Wellness Evaluation Form and open it in your preferred editing tool.
2. Begin with Section I: Member/Provider Information. Users should fill out their last name, first name, middle initial, date of birth, and member ID number as found on their ID card. Ensure this information is printed clearly.
3. Next, the provider completes their information. This includes the provider name, provider ID number, effective date of coverage, and provider phone number. Double-check this section for accuracy.
4. In Section II: Health Measures, your provider will need to indicate tobacco use, blood pressure, cholesterol levels, weight, flu shot status, and immunizations and screenings. This section requires input from the healthcare provider, so ensure they have the necessary details during your visit.
5. For each health measure, the provider should check the appropriate boxes and record the date measured. If any measures can be waived due to pregnancy, ensure this is noted.
6. After completing the necessary sections, both the member and provider must sign and date the form confirming the accuracy of the information provided.
7. Once completed, save the changes, and you can either download, print, or share the form electronically as needed.

Take action today by filling out your Wellness Evaluation Form online to support your health journey.