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 civilrightscoordinator@carefirst.com 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:civilrightscoordinator@carefirst.comhttps://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.

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