Primary Care Provider (PCP) Form Participant Steps
**We DO NOT suggest asking the Physician’s Office to fax in the
completed PCP Form. It is the responsibility of the Participant to submit
the competed PCP Form. Follow the steps exactly as listed below.
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Access and Print a Company Specific PCP Form.
Complete all fields listed under Patient Information.
Write your Screening Appointment Date on the PCP Form.
Provide the PCP Form to your physician during your annual visit for completion of Blood Pressure, Height,
Weight, and Waist Circumference fields.
Complete the Fasting Status field.
Have your physician sign the PCP Form.
Ask your physician when and how you will be receiving your blood work/lab results. Let your physician
know these results are required for your PCP Form.
Upon receiving your blood work/lab results from your physician, complete the Total Cholesterol, HDL, LDL,
Triglycerides, and Glucose fields on the PCP Form.
Sign and date the PCP Form.
All information is required on the form before submitting to TotalWellness. Forms must be signed by
you and your physician to be considered complete for processing. The Screening Date must also be
included.
Submit the completed PCP Form to TotalWellness using one of 3 options. ONLY SUBMIT ONE FORM.
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Send your completed PCP Form by Secure Fax to: 402-939-0458, OR
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Upload your completed Form using our Secure Online Submission at the URL provided on the PCP
Form. OR
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Mail to TotalWellness
Attention: Data Team
9320 H Court
Omaha, NE 68127
Receipt Confirmations are emailed to participants within 2-4 days. An email address MUST be included on
the Form in order for this email confirmation to be sent. If you do not receive email confirmation after 4
days of submission, please contact Data Support at [email protected] or 888-4344358 x127 to verify that the PCP Form was received. Please indicate the company you work for.
Reminders
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Do Not Re-Fax/Submit the PCP Form unless instructed by TotalWellness.
Forms MUST be submitted on or before the Program End Date listed on the Form. Forms received after
the End Date will not be processed.
TotalWellness does NOT accept any form or document other than the Approved Company Specific PCP
Form.
All Questions regarding form submissions should be directed to Data Support via email at
[email protected] or phone at 888.434.4358 ext. 127.
Reviewed 3/2/16
Frequently Asked Questions
Q. I faxed in my form and I have not received a confirmation email OR I want to verify that it was received.
A. Do Not Re-Fax unless instructed by TotalWellness.
 Allow up to 2 - 4 days for processing.
 If 5 days have passed, please contact [email protected] or at 888.434.4358 ext. 127.
Q. I don’t have a fax machine, OR Internet access, AND/OR a scanner.
A. Participants can Mail the completed PCP Form to:
TotalWellness
Attention: Primary Care Provider Form
9320 H Court
Omaha, NE 68127
Q. I went to my Physician for my physical but he/she did not provide me with values for Total Cholesterol, HDL,
LDL, Triglycerides and/or Glucose.
A. Most blood work has to be processed by the lab.
 Participants should contact their Physician’s office on when and how the lab will be providing the lab
results.
 Upon receiving the lab results from their physician, have the participant complete the Total Cholesterol,
HDL, LDL, Triglycerides, and Glucose fields on the PCP Form.
 Have the participant verify that all fields are complete, sign and date the completed Form and Fax or
Submit via Online Submission.
Reviewed 3/2/16