FY17 “I’M HEALTHY” SCREENING FORM
**DUE TO JESS BROWN IN HR BY THE END OF MAY**
DIRECTIONS FOR THE EMPLOYEE: Please look over this form carefully before taking it to your provider. To qualify for the discount
using this form, all health indicators must fall within either the desired health target or threshold ranges listed below as of June of 2016.
Your wellness coordinator or healthcare provider should mark each appropriate biometric box and then initial in the right hand column.
This form MUST be signed by your provider to verify that you have had a wellness checkup with them between 7/1/16 and 5/31/17.
There is also a space for your dentist’s signature OR you may supply a copy of Premera’s Explanation of Benefits. This can be found in your
Premera online health portal.
DIRECTIONS FOR THE PROVIDER: Please review and discuss the health information below during your patient’s annual wellness check
and sign below. Mark the appropriate boxes for each health indicator and initial the boxes to the right. If you have any questions, please
contact Jess Brown at 586-0206. Thank you!
PATIENT INFORMATION (PLEASE PRINT)
Patient’s last name:
First:
Middle:
Age:
Sex:
M
Phone number:
Department:
F
Employer:
Don’t forget…

Health Yourself offers FREE glucose and cholesterol screenings in the fall. You can also make an appointment to do this at a later
date with the CBJ/BRH Wellness Coordinator at no cost.

Remind your provider that preventative screening services, such as wellness exams, appropriate cancer screenings and
immunizations should be billed as preventative wellness exams.

Our insurance allows one wellness exam every fiscal year, and a preventive dental cleaning every six months, covered at 100% at
in-network providers.
ANNUAL PHYSICAL/WELLNESS EXAM (MUST BE FROM JUNE 1, 2016- MAY 31, 2017)
Health Indicator
Tobacco Use
Cholesterol Risk Ratio
(Tot/ HDL)
Non-fasting Glucose
OR
Fasting Glucose
(No caloric intake for at least 10 hours)
Blood Pressure
Body Mass Index
(appropriate body fat % may be substituted)
Wellness Checkup
Desired Health Target
Threshold for Discount
Non-Tobacco User
Women: Risk ratio
less than 3.3
Men: Risk ratio
less than 3.4
Women: Risk ratio
less than 4.4
Men: Risk ratio
less than 5.0
Does not Meet
Threshold
Medical Provider or
Wellness Coordinator
Initial to Verify
Tobacco User
_______
Women: Over 4.4
Men: Over 5.0
Normal (<140 mg/dl)
Up to 140
Over 140
Normal (70-99 mg/dl)
Up to 120
Over 120
Up to 120/80
Up to 130/90
Up to 25
Up to 30
Over 130/90
Over 30
_______
_______
_______
_______
I have reviewed the information above and have discussed all results with the patient. This patient has
completed his or her annual wellness physical since June 1, 2016 and is complying with my
recommendations to treat any chronic condition(s) and improve health.
Healthcare provider signature: ___________________________ Date_________
Preventative Dental Cleaning
Healthcare provider’s printed name:___________________________________________
This patient has had at least one preventative dental cleaning since June 1, 2016.
Dentist/Dental Hygienist signature: _______________________ Date _________
(or provide a copy of you Premera Explanation of Benefits)
I hereby certify that all of the information provided on this form is true and complete to the best of my knowledge and
belief, and that I have not knowingly provided false information.
Employee Signature _____________________________ Printed Name: ___________________________ Date ___________