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Get MI DCH-1315 2018-2024

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 orientation gender identity or expression political beliefs or disability. We want to ask you a few questions about your current health. Your doctor and your health plan will use this information to better meet your health needs. The information you provide in this form is personal health information protected by federal and state law and will be kept confidential* It CANNOT be used to deny health care coverage. We also encourage you to see your doctor for a check-up as soon as possible after you enroll with a health plan and at least once a year after that. An annual check-up appointment is a covered benefit of the Healthy Michigan Plan* Contact your health plan if you need transportation assistance to get to and from this appointment. If you need assistance with completing this form contact your health plan* You can also call the Beneficiary Help Line at 1-800-642-3195 or TTY 1-866-501-5656 if you have questions. Call your doctor s office to schedule an annual check-up appointment. Take this form with you to your appointment. Your doctor or other primary care provider will complete section 4. He or she will send your results to your health plan* There is a Healthy Behavior Reward for agreeing to address or maintain healthy behaviors on your health risk assessment. This reward can be a gift card or a reduction in monthly MI Health Account payments depending on your income. Don t forget to complete a new health risk assessment each year. After your appointment keep a copy or printout of this form that has your doctor s signature on it. This is your record that you completed your annual Health Risk Assessment. DCH-1315 12/17 Page 1 of 5 First Name Middle Name Last Name and Suffix Date of Birth mm/dd/yyyy Mailing Address Apartment or Lot Number City State Zip Code Phone Number mihealth Card Number Other Phone Number SECTION 1 - Initial assessment questions check one for each question In general how would you rate your health Has a doctor told you that you have hearing loss or are deaf Yes For women only Are you currently pregnant In the last 7 days how often did you exercise for at least 20 minutes in a day Every day 3-6 days 1-2 days Excellent Very Good Good Fair Poor No Not applicable men only 0 days Exercise includes walking housekeeping jogging weights a sport or playing with your kids.

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