Get Healthcare Provider Screening Form - Rsa-al

Completing the Healthcare Provider Screening Form - Rsa-al online is a crucial step for users participating in the Wellness Program. This guide will walk you through each section to ensure your form is accurately filled out and submitted.

Follow the steps to successfully complete the form online.

1. Click ‘Get Form’ button to obtain the form and open it in the suitable editor.
2. Begin with Section 1, which is to be completed by the active or retired employee or spouse. Enter the required PEEHIP PID, participant's SSN, screening date, birth date, and zip code. Ensure to print clearly using a black ink pen.
3. Select the appropriate gender by darkening the box completely for either 'Male' or 'Female,' indicating if you are the contract holder or spouse.
4. If applicable, indicate the reason for not performing the screening, such as pregnancy, and complete the race/ethnicity section by selecting the relevant option.
5. Answer the questions regarding any existing medical conditions by indicating if you have been diagnosed with high cholesterol, high blood pressure, or diabetes. Also, specify if you are taking medication for these conditions.
6. Proceed to Section 2, which should be filled out by the healthcare provider. This section will require measurements such as blood pressure, blood glucose, cholesterol levels, height, weight, waist measurement, and waist-to-height ratio.
7. The healthcare provider must indicate whether the patient has used tobacco products or electronic smoking devices in the last year. All measurements must be recorded accurately.
8. Finally, the healthcare provider should print their name, type, address, and phone number. Make sure to include the provider’s signature before submitting the form.
9. Once completed, save any changes made to the form, and use the options available to download, print, or share the form as necessary.

Ensure your document is complete and submit your Healthcare Provider Screening Form - Rsa-al online today.