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Health and Wellness Evaluation Form
Section I: Participant Information to be completed by Participant annually
Last Name First Name MI
Date of Birth / /
yyyy
Gender
Male Female
Phone - -Number _______ ________ _________
mm dd
If insured by CareFirst BlueCross BlueShield: If not insured by CareFirst BlueCross BlueShield:
Group Number Employer Name
Member ID Number Alternate ID Number
Please select one:
Initial Screening
Rescreening (For Participants who purchase insurance through an employer only) Check measures to be rescreened: Weight Flu Vaccine Tobacco Blood Pressure Blood Glucose Cholesterol
Section II: Provider Information to be completed by Provider
Provider Name
Provider ID Number Provider Phone Number
Section III: Health Measures to be completed by ProviderPlease provide measurements for each category below, or if it is not medically advisable for your patient to be measured on a specific health factor based on clinical circumstances, please indicate Waiver.
Alternative Standards: Patients who receive insurance through their employer may be eligible for an incentive based on their results. Please see directions below for setting alternative standards, if applicable.
During the Initial Screening: During the Rescreening:
I f your patient doesnt meet the recommended goal, you If you recommended an Alternative Standard Set during the can determine an acceptable alternative. Check Alternative initial screening, please check Alternative Standard Met if the Standard Set. patients goal was reached at the rescreening and fill out the new
measurements where indicated. If you check Alternative Standard Set, please develop an alternate goal for the patient to meet, including a plan to improve and maintain his/her health.
1. Weight (required for ages 2 and older) Waiver provided by PCP
Date measured: / Adult BMI: Child BMI: percentile mm yyyy
Adult Height: in Adult Weight: lbs Adult Waist Measurement: in
GOAL: Adult Body Mass Index (BMI) is between 19 and less than 30 Child BMI is in the 5th to 85th percentile depending on age and gender
If applicable: Alternative Standard Set at initial screening Alternative Standard Met at rescreening (continued)
CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. are both independent licensees of the Blue Cross and Blue Shield Association.
Registered trademark of the Blue Cross and Blue Shield Association. Registered trademark of CareFirst of Maryland, Inc.SUM2663-1P (3/15)
Section III: Health Measures
(continued)
2. Flu Vaccine (required for ages 2 and older) Waiver provided by PCP
Up-to-date on Flu Vaccine? Yes No Date of last Vaccine: /yyyy mm
GOAL: Within last 18 months
3. Tobacco Use (required for ages 18 and older) Waiver provided by PCP
Date measured: / mm yyyy
Non-Smoker Smoker
GOAL: Non-smoker (never smoked or quit for more than 30 days)
If applicable: Alternative Standard Set at initial screening Alternative Standard Met at rescreening
4. Blood Pressure (required for ages 18 and older) Waiver provided by PCP
Date measured: / BP Reading: / mm yyyy
GOAL: Less than 140/90 (ages 18-59); Less than 150/90 (ages 60+)
If applicable: Alternative Standard Set at initial screening Alternative Standard Met at rescreening
5. Blood Glucose (required for ages 18 and older) Waiver provided by PCP
Fasting* Date measured: /
mm yyyy Yes NoBlood Glucose Reading: Fasting*
GOAL: Fasting Blood Glucose is less than 100
If applicable: Alternative Standard Set at initial screening Alternative Standard Met at rescreening
6. Cholesterol (for ages 18 and older) Waiver provided by PCP
Fasting* Date measured: /
mm yyyy Yes No
GOAL: Collect fasting baseline data
Total Cholesterol:
LDL: HDL: Triglycerides:
If applicable: Alternative Standard Set at initial screening Alternative Standard Met at rescreening
*This means you have not had anything to eat or drink other than water or coffee/tea without sugar or cream in the last 9-12 hours.
Section IV: Screening Signatures
I hereby certify that the information provided on this form is true and accurate to the best of my personal knowledge and understand that any material misrepresentation(s) will disqualify my dependents, if applicable, and me from receiving any incentive if incentives are included in my program.
Participant Signature Date Provider Signature Date
Submission Instructions for Participant: Submit the results of this completed form by logging into My Account at www.carefirst.com. Please check your enrollment materials for specific submission deadline requirements.
If you dont have Internet access, you can submit this form by fax to 800-354-8205 or by mail to: Mail Administrator, P.O. Box 14116, Lexington, KY 40512-4116
CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst of Maryland, Inc., Group Hospitalization and Medical Services, Inc., CareFirst BlueChoice, Inc., First Care, Inc. and The Dental Network are independent licensees of the Blue Cross and Blue Shield Association. Registered trademark of the Blue Cross and Blue Shield Association.
Registered trademark of CareFirst of Maryland, Inc.
Notice of Nondiscrimination and Availability of Language Assistance Services
CareFirst BlueCross BlueShield, CareFirst BlueChoice, Inc. and all of their corporate affiliates (CareFirst) comply with applicable federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability or sex. CareFirst does not exclude people or treat them differently because of race, color, national origin, age, disability or sex. CareFirst:
Provides free aid and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats, other formats)
Provides free language services to people whose primary language is not English, such as: o Qualified interpreters o Information written in other languages
If you need these services, please call 855-258-6518. If you believe CareFirst has failed to provide these services, or discriminated in another way, on the basis of race, color, national origin, age, disability or sex, you can file a grievance with our CareFirst Civil Rights Coordinator. Civil Rights Coordinator, Corporate Office of Civil Rights Telephone Number 410-528-7820
Mailing Address P.O. Box 8894 Baltimore, Maryland 21224
Fax Number 410-505-2011
Email Address [email protected] You can file a grievance by mail, fax or email. If you need help filing a grievance, our CareFirst Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 800-368-1019, 800-537-7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
mailto:[email protected]://ocrportal.hhs.gov/ocr/portal/lobby.jsfhttp://www.hhs.gov/ocr/office/file/index.html
CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst of Maryland, Inc., Group Hospitalization and Medical Services, Inc., CareFirst BlueChoice, Inc., First Care, Inc. and The Dental Network are independent licensees of the Blue Cross and Blue Shield Association. Registered trademark of the Blue Cross and Blue Shield Association.
Registered trademark of CareFirst of Maryland, Inc.
Foreign Language Assistance Attention (English): This notice contains information about your insurance coverage. It may contain key dates
and you may need to take action by certain deadlines. You have the right to get this information and assistance in
your language at no cost. Members should call the phone number on the back of their member identification card.
All others may call 855-258-6518 and wait through the dialogue until prompted to push 0. When an agent
answers, state the language you need and you will be connected to an interpreter.
(Amharic) -
855-258-6518 0
d Yorb (Yoruba) ttlko: kys y n wfn npa i adjtf r. le n wn dt pt o s le n lti
gb gbs n wn j gbdke kan. O ni t lti gba wfn y ti rnlw n d r lf. wn m-gb
gbd pe nmb fn t w lyn kd dnim wn. wn mrn le pe 855-258-6518 k o s dr npas jrr
tt a fi s fn lti t 0. Ngbt aoj kan b dhn, s d t o f a s so p m gbuf kan.
Ting Vit (Vietnamese) Ch : Thng bo ny cha thng tin v phm vi bo him ca qu v. Thng bo c th
cha nhng ngy quan trng v qu v cn hnh ng trc mt s thi hn nht nh. Qu v c quyn nhn
c thng tin ny v h tr bng ngn ng ca qu v hon ton min ph. Cc thnh vin nn gi s in thoi
mt sau ca th nhn dng. Tt c nhng ngi khc c th gi s 855-258-6518 v ch ht cuc i thoi cho
n khi c nhc nhn phm 0. Khi mt tng i vin tr li, hy nu r ngn ng qu v cn v qu v s c
kt ni vi mt thng dch vin.
Tagalog (Tagalog) Atensyon: Ang abisong ito ay naglalaman ng impormasyon tungkol sa nasasaklawan ng iyong
insurance. Maaari itong maglaman ng mga pinakamahalagang petsa at maaaring kailangan mong gumawa ng
aksyon ayon sa ilang deadline. May karapatan ka na makuha ang impormasyong ito at tulong sa iyong sariling
wika nang walang gastos. Dapat tawagan ng mga Miyembro ang numero ng telepono na nasa likuran ng kanilang
identification card. Ang lahat ng iba ay maaaring tumawag sa 855-258-6518 at maghintay hanggang sa dulo ng
diyalogo hanggang sa diktahan na pindutin ang 0. Kapag sumagot ang ahente, sabihin ang wika na kailangan mo
at ikokonekta ka sa isang interpreter.
Espaol (Spanish) Atencin: Este aviso contiene informacin sobre su cobertura de seguro. Es posible que
incluya fechas clave y que usted tenga que realizar alguna accin antes de ciertas fechas lmite. Usted tiene
derecho a obtener esta informacin y asistencia en su idioma sin ningn costo. Los asegurados deben llamar al
nmero de telfono que se encuentra al reverso de su tarjeta de identificacin. Todos los dems pueden llamar al
855-258-6518 y esperar la grabacin hasta que se les indique que deben presionar 0. Cuando un agente de seguros
responda, indique el idioma que necesita y se le comunicar con un intrprete.
(Russian) !
. ,
.
. ,
.
855-258-6518 , 0.
, .
CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst of Maryland, Inc., Group Hospitalization and Medical Services, Inc., CareFirst BlueChoice, Inc., First Care, Inc. and The Dental Network are independent licensees of the Blue Cross and Blue Shield Association. Registered trademark of the Blue Cross and Blue Shield Association.
Registered trademark of CareFirst of Maryland, Inc.
(Hindi) : - 855-258-6518 0 ,
s-w (Bassa) To uu Cao! B nia k a ny e ke m gbo kpa o ni fu a-fa-tiin ny je dyi. B nia k
ee we j e m ke wa m m ke nyu nyu hw we ea ke zi. m ni kpe m ke b nia k ke gbo-
kpa-kpa m m dye e ni ii-wuu mu m ke se wii o p. Kpoo ny e m a fn-na nia e waa
I.D. kaa ein ny. Ny t sein m a na nia k: 855-258-6518, ke m m fo tee wa ke m gbo c m ke
na ma 0 k dyi paain hw. ju ke ny o dyi m g juin, po wuu m m po dyi, ke ny o mu o niin
ke ni wuu mu za.
(Bengali) : 855-258-6518 0
: (Urdu )
0 6518-258-855
: . (Farsi ). .
.
. 0 855-258-6518
.
: (Arabic) . .
.
.0 855-258-6518
.
(Traditional Chinese)
855-258-6518
0
CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst of Maryland, Inc., Group Hospitalization and Medical Services, Inc., CareFirst BlueChoice, Inc., First Care, Inc. and The Dental Network are independent licensees of the Blue Cross and Blue Shield Association. Registered trademark of the Blue Cross and Blue Shield Association.
Registered trademark of CareFirst of Maryland, Inc.
Igbo (Igbo) Nrbama: kwa a nwere ozi gbasara mkpuchi nchekwa onwe g. nwere ike nwe bch nd d
mkpa, nwere ike me ihe tupu fd bch njedebe. nwere ikike nweta ozi na enyemaka a nass g na
akwgh gw bla. Nd otu kwesr kp akara ekwent d naz nke kaad njirimara ha. Nd z niile nwere
ike kp 855-258-6518 wee chere bb ah ruo mgbe amanyere p 0. Mgbe onye nnchite anya zara, kwuo
ass chr, a ga-ejik g na onye kwa okwu.
Deutsch (German) Achtung: Diese Mitteilung enthlt Informationen ber Ihren Versicherungsschutz. Sie kann
wichtige Termine beinhalten, und Sie mssen gegebenenfalls innerhalb bestimmter Fristen reagieren. Sie haben
das Recht, diese Informationen und weitere Untersttzung kostenlos in Ihrer Sprache zu erhalten. Als Mitglied
verwenden Sie bitte die auf der Rckseite Ihrer Karte angegebene Telefonnummer. Alle anderen Personen rufen
bitte die Nummer 855-258-6518 an und warten auf die Aufforderung, die Taste 0 zu drcken. Geben Sie dem
Mitarbeiter die gewnschte Sprache an, damit er Sie mit einem Dolmetscher verbinden kann.
Franais (French) Attention: cet avis contient des informations sur votre couverture d'assurance. Des dates
importantes peuvent y figurer et il se peut que vous deviez entreprendre des dmarches avant certaines chances.
Vous avez le droit d'obtenir gratuitement ces informations et de l'aide dans votre langue. Les membres doivent
appeler le numro de tlphone figurant l'arrire de leur carte d'identification. Tous les autres peuvent appeler le
855-258-6518 et, aprs avoir cout le message, appuyer sur le 0 lorsqu'ils seront invits le faire. Lorsqu'un(e)
employ(e) rpondra, indiquez la langue que vous souhaitez et vous serez mis(e) en relation avec un interprte.
(Korean) : . .
. ID .
855-258-6518 0 .
.
Male or Female: Screening: Last name: First name: Middle initial: Month of Birth: Date of Birth: Year of Birth (4 digits): phone 3: phone 2: phone 1: Group Number: Employee Name : Member ID number: Alternate ID Number: Weight: Tobacco: Blood Pressure: Blood Glucose: Cholesterol: Flu Vaccine: