Healthcare Provider Screening Form - rsa-al 2025

1. Click ‘Get Form’ to open the Healthcare Provider Screening Form - rsa-al in the editor.
2. Begin by completing the Prior Authorization section. Ensure you read and understand the privacy notice before signing.
3. In Section 1, provide your PEEHIP PID, Patient SSN, and screening date. Fill in your birth date and select your gender by darkening the appropriate box completely.
4. Enter your last name, first name, and zip code. If applicable, indicate if screening was not performed due to pregnancy or disability.
5. Select your race/ethnicity from the provided options and indicate any medical conditions you have or medications you take related to high cholesterol, blood pressure, or diabetes.
6. Section 2 is for the healthcare provider. They will fill in details such as blood pressure readings, cholesterol levels, height, weight, waist measurements, and tobacco use.
7. Finally, ensure that both you and your healthcare provider sign the form before submitting it via fax or mail to the ADPH Wellness Program.

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