Wellness Screening Physician Form - Wisconsin Conference United ...

Physician Results Form
* Completed form must be faxed to 1-855-794-1391 *
Patient’s Employer Wellness Program Information
Account: HealthFlex-General Board of Pension QLS Number 97560832
and Health Benefits-United Methodist Church
Wellness Individual Completes
Wellness Individual Name (Last, First, Middle Initial)
Email Address
Last 7 digits on Medical Card, plus “S” if a covered spouse Date of Birth (MM/DD/YYYY) Phone
Wellness Individual Signature
Date
The information provided on this form will be kept confidential.
Physician Office Completes
Date of Testing Testing and measurements must be completed April 1, 2013 – July 31, 2013.
Biometric Screening Measurement
Height (ft., in.) REQUIRED
Weight (lbs.) REQUIRED
Screening Values
Enter NG for any result not available for reporting.
Waist Circumference REQUIRED
Blood Pressure REQUIRED
Cardio CRP
Glucose REQUIRED
Hemoglobin A1c
Total Cholesterol (mg/dl) REQUIRED
Triglycerides REQUIRED
HDL Cholesterol (mg/dl) REQUIRED
LDL Cholesterol (mg/dl) REQUIRED
Inches:
Systolic
Diastolic
Physician or Physician Designee’s Signature
Physician Office – Below Information Must Be Complete to Process
Date
Physician’s Name (please print) UPIN/NPI Phone Number
Wellness Participant Information:
• Physician Results Report Form option is available for those participants who cannot participate at an on-site event or Quest patient service center.
• By submitting this form, you are requesting your physician to report laboratory and biometric results to Quest Diagnostics for your Blueprint for Wellness
Screening. Testing must be completed between April 1 and July 31, 2013. All REQUIRED tests must be reported to be eligible for the $100 HealthCash
incentive.
• You are responsible for ensuring your doctor returns this form by July 31, 2013. Your results will not be processed if your form is received after July 31.
• For an individual participant, only one physician form can be submitted.
• Physician results cannot be combined with or used to override any actual measured results by Quest Diagnostics.
For questions, please contact the Blueprint for Wellness Customer Support Center by email at
wellness@questdiagnostics.com or by call 1-866-908-9440 (available Monday to Friday 7 a.m. – 8:30 p.m. CST and Saturday 7:30 a.m. – 4 p.m. CST).