Get Biometrics Screening Results Provider Form - Providence Health ... - Alaska Providence

This guide provides step-by-step instructions for completing the Biometrics Screening Results Provider Form for Providence Health in Alaska. Designed for users of all experience levels, this comprehensive guide will help ensure your form is filled out accurately and completely.

Follow the steps to successfully complete your biometrics screening results form.

1. Press the ‘Get Form’ button to obtain the Biometrics Screening Results Provider Form and open it for filling out.
2. Complete Part I of the form as the eligible member. This includes stating the reason for submitting the form, providing your first and last name exactly as they appear on official records, date of birth, and contact information. Ensure to complete all fields marked with an asterisk (*) since they are mandatory.
3. In the Member Attestation/Authorization section, indicate your agreement to allow your provider to report the required results to Healthyroads. Sign and date this section to provide the necessary authorization.
4. Proceed to Part II of the form, which will be completed by your healthcare provider. Ensure you attend a preventive health visit where your provider will fill out this section with their findings and necessary details.
5. Confirm that all sections of the form are filled out accurately and legibly. If your provider needs to confirm any laboratory or biometric results, ensure they do so before submitting the form.
6. After completion, save a copy of the filled form for your records. It is crucial to maintain this for documentation purposes.
7. Submit the completed form by fax to 1-877-495-2746, email securely to PhysicianReportedForms@ashn.com, or mail it to Healthyroads at the specified address before the submission deadline.

Complete your Biometrics Screening Results Provider Form online now to ensure you receive your incentive credit.