Health Screening Results Please Note: This form is NOT a physician ... 2026

1. Click ‘Get Form’ to open it in the editor.
2. In Section 1, enter your personal details including your name, age, date of birth, and gender. Select your status as either Employee or Spouse/Domestic Partner.
3. Provide the last four digits of your Associate’s SSN and, if applicable, the employee's name if you are a spouse.
4. Fill in your email address and phone number. Ensure all fields marked as required are completed for processing.
5. Sign and date the form at the bottom of Section 1 to give permission for your healthcare provider to send results to Provant.
6. Section 2 will be completed by your healthcare provider. Ensure they fill in all necessary health metrics such as cholesterol levels and blood pressure.
7. Once both sections are filled out, review the information for accuracy before submitting it via fax or mail as indicated.

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