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Viverae form 2026

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The document is a Physician Screening Collection Form for Abilene Christian University, intended for physician offices to submit biometric screening results on behalf of participants who cannot attend onsite screenings. It outlines the necessary information required from both the participant and their healthcare provider, emphasizes confidentiality and HIPAA compliance, and specifies the tests needed for wellness program credit.

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Click ‘Get Form’ to open the viverae form in the editor.
Begin by entering your personal information in the designated fields. Fill in your name, employer, date of birth, and phone number accurately.
Next, provide your healthcare provider's details. This includes their name, clinic, phone number, and address. Ensure all information is correct for seamless communication.
In the 'Lab & Screening Tests' section, enter the test date and fill in the values for each test parameter listed. Make sure to include units where applicable.
Indicate whether you were fasting before the tests by selecting 'YES' or 'NO'.
Finally, review all entries for accuracy before submitting. Once completed, fax the form to Viverae as instructed.

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