Health and Wellness Evaluation Form Health and Wellness Evaluation Form - bowiestate 2026

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  1. Click ‘Get Form’ to open the Health and Wellness Evaluation Form in the editor.
  2. Begin with Section I: Member/Provider Information. Fill in your last name, first name, middle initial, member ID number, gender, date of birth, and effective date of coverage. Ensure all fields are completed clearly.
  3. Next, move to the Provider Information section. The provider will need to fill in their name, ID number, and phone number.
  4. Proceed to Section II: Health Measures. This section must be completed by your provider. They will assess tobacco use, blood pressure, cholesterol levels, weight, flu shot status, and necessary immunizations or screenings.
  5. Once all sections are filled out accurately, both you and your provider must sign and date the form at the bottom.
  6. Finally, submit the completed form within 180 days of your effective date through our platform or by fax/mail as instructed.

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