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Provider Screening Form IB13

Provider Screening Form IB13

 

INSTRUCTIONS: ALABAMA PROVIDER SCREENING FORM (Form IB13)

 

 

Alabama state employees who choose not to participate in Worksite Wellness screenings may instead submit health screening results through a healthcare provider. This is done using a form IB13. This document can be obtained from the website of the Alabama State Employees' Insurance Board.

 

Alabama Provider Screening Form IB13 Step 1: Section 1 should be completed by the employee. In the first blank box, enter your name.

 

Alabama Provider Screening Form IB13 Step 2: In the second blank box, enter the screening date.

 

Alabama Provider Screening Form IB13 Step 3: In the third blank box, indicate whether you are male or female with a check mark.

 

Alabama Provider Screening Form IB13 Step 4: In the fourth blank box, enter your age.

 

Alabama Provider Screening Form IB13 Step 5: In the fifth blank box, enter your contract number.

 

Alabama Provider Screening Form IB13 Step 6: In the sixth blank box, enter your Social Security number.

 

Alabama Provider Screening Form IB13 Step 7: In the seventh blank box, enter your date of birth.

 

Alabama Provider Screening Form IB13 Step 8: In the eighth blank box, enter your daytime telephone number.

 

Alabama Provider Screening Form IB13 Step 9: Indicate your race or ethnicity with a check mark.

 

Alabama Provider Screening Form IB13 Step 10: Indicate with a check mark whether you have or have been told you have high cholesterol, high blood pressure or diabetes.

 

Alabama Provider Screening Form IB13 Step 11: Indicate with a check mark whether you take any medication for the conditions listed in step 10.

 

Alabama Provider Screening Form IB13 Step 12: The second section should be completed by your health care provider. They will detail your blood pressure, total cholesterol, HDL and LDL cholesterol, triglycerides, blood glucose, height, weight, body mass index, waist measurement, and waist/height ratio.

 

Alabama Provider Screening Form IB13 Step 13: On the next blank line, the provider should print their name.

 

Alabama Provider Screening Form IB13 Step 14: On the next blank line, the provider should enter their signature.

 

Alabama Provider Screening Form IB13 Step 15: On the next blank line, the provider should enter their address.

 

Alabama Provider Screening Form IB13 Step 16: The completed form should be returned to the State Employees' Insurance Board at the address given at the bottom of the page.

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