Health Risk Assessment INSTRUCTIONS The Healthy Michigan Plan is very interested in helping you get healthy and stay healthy. You can also learn more at this website www. healthymichiganplan.org. Instructions for completing this Health Risk Assessment for Healthy Michigan Plan Answer the questions in sections 1-3 as best you can. You are not required to answer all of the questions. I have provided a copy of this Health Risk Assessment to the member listed above. Provider Last Name Provider First Name National Provider Identifier NPI Provider Telephone Number Signature Date Submit form by fax or via CHAMPS Fax to 517-763-0200 CHAMPS The Health Risk Assessment form can be submitted and viewed in the CHAMPS system via the Health Risk Assessment Questionnaire Web Page. The Michigan Department of Health and Human Services does not discriminate against any individual or group because of race religion age national origin color height weight marital status genetic information sex sexual orient....
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How to fill out the MI DCH-1315 online
This guide provides essential instructions for completing the MI DCH-1315 form online. By following the outlined steps, users can efficiently provide their health information, which will be used to enhance their care under the Healthy Michigan Plan.
Follow the steps to complete the MI DCH-1315 form.
- Click the ‘Get Form’ button to retrieve the MI DCH-1315 and open the document in your preferred online editor.
- Enter your personal information in the designated fields at the beginning of the form. This includes your first name, middle name, last name, suffix (if applicable), date of birth, mailing address, phone number, and MI Health Card number. Ensure that this information is accurate and up to date.
- Proceed to Section 1, where you will respond to initial assessment questions. For each question, select the answer that best represents your current health status or situation. Remember that not all questions require a response, and providing accurate information helps in meeting your healthcare needs.
- In Section 2, you will fill out details regarding your annual check-up appointment. Enter the date of your appointment in the provided field and specify any topics you wish to discuss with your doctor.
- Section 3 requires you to reflect on your readiness to make changes to improve your health. Answer the questions on a scale of 0 through 5, considering the support you feel you would receive from family, friends, and your healthcare provider.
- Section 4 is to be completed by your primary care provider. Ensure that they fill out the necessary parts during your appointment. This includes assessing your health behavior goals and providing their attestation.
- After your appointment, make sure to save a copy of the completed form, particularly the section signed by your primary care provider. This document serves as your record of participation in the Health Risk Assessment.
- Finally, once you have filled out all applicable sections, save your changes, download a copy, print the form, or share it as necessary. Follow any further instructions provided for submitting the completed document.
Complete your MI DCH-1315 form online today to take an active role in your health care.
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DCH-1315 (10/18). Page 1 of 5. Health Risk Assessment. INSTRUCTIONS. The Healthy Michigan...
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