Inova WellAware Health Screening at a glance
What it is: Inova WellAware Health Screening is a health screening form.
Who signs: Sign on the Patient Signature line and enter the Date.
A filled-in Inova WellAware Health Screening example: an employee fills out the form
How to fill out Inova WellAware Health Screening, box by box
Employee or Spouse or Domestic Partner
Please select one: Employee or Spouse or Domestic Partner.
Patient information
Under PATIENT INFORMATION, enter Last Name, First, Middle, Address (Home or Mailing), City, State and Zip Code.
Enter Age, Date of Birth, Primary Phone, Secondary Phone, Sex (M or F) and Email.
Enter the Employer Name.
Your physician information
Under YOUR PHYSICIAN INFORMATION, enter the Physician's Name.
Location of employment
Please select your location of employment, or "spouse" if applicable.
Custom panels
Under CUSTOM PANELS, the Custom Employer Panel lists Lipid Panel, hsCRP, Insulin, Glucose, HbA1c, TSH, ALT, Creatinine, Cystatin C, LDL-P & HDL-P.
Patient consent
Under PATIENT CONSENT, the blood testing service from HDL is provided solely for informational purposes and is not being used as a substitute for the care, medical advice, or treatment provided by your primary care physician.
You are solely responsible for forwarding your test results to your primary care physician and following up with that individual.
When you participate in a blood test from HDL, you are doing so with the understanding that you/your employer is privately paying for these tests and there will be absolutely no billing to Medicare, Medicaid, or private insurance.
Notice of privacy practices
Under NOTICE OF PRIVACY PRACTICES, sign and date to acknowledge that you have reviewed HDL Notice of Privacy Practices and that you are entitled to receive a copy of the notice upon request.
More rules for Inova WellAware Health Screening
This form must be typed, signed, printed and brought to your health assessment appointment; handwritten copies will NOT be accepted.
Sources
[1] Inova WellAware Health Screening (the Official source link on this page).
