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Click ‘Get Form’ to open the VOLUNTARY HEALTH SCREENING in the editor.
Begin by completing SECTION 1. Fill in your name, insurance number, group number, and date of screening. Indicate your gender and age, and provide your last four digits of your Social Security Number along with your date of birth.
Next, provide your daytime phone number and email address. Mark any medical conditions you have been diagnosed with from the list provided, including high cholesterol, high blood pressure, or diabetes.
Indicate if you take medication for any of these conditions by marking the appropriate boxes.
Once SECTION 1 is complete, ensure that all information is accurate before moving on to SECTION 2, which will be filled out by your provider during the screening.
After the screening is completed by your provider, review their entries for accuracy before submitting the form to LGHIB by the specified deadline.

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