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Form IB13 Provider Screening Form

Form IB13 Provider Screening Form

 

INSTRUCTIONS: ALABAMA STATE EMPLOYEES' HEALTH INSURANCE PLAN PROVIDER SCREENING PLAN (Form IB13)

 

 

Alabama state employees who cannot or choose not to participate in the state employees' insurance board Worksite Wellness program can submit health screening results through your healthcare provider using this form. This document can be obtained from the website maintained by the Alabama State Employees' Insurance Board.

 

Alabama State Employees' Health Insurance Plan Provider Screening Plan IB13 Step 1: Section 1 should be completed by you. Enter your name in the first blank box.

 

Alabama State Employees' Health Insurance Plan Provider Screening Plan IB13 Step 2: Enter the screening date in the second blank box.

 

Alabama State Employees' Health Insurance Plan Provider Screening Plan IB13 Step 3: Indicate whether you are male or female with a check mark.

 

Alabama State Employees' Health Insurance Plan Provider Screening Plan IB13 Step 4: Enter your age in the third blank box.

 

Alabama State Employees' Health Insurance Plan Provider Screening Plan IB13 Step 5: Enter your contract number in the fourth blank box.

 

Alabama State Employees' Health Insurance Plan Provider Screening Plan IB13 Step 6: Enter your Social Security number in the fifth blank box.

 

Alabama State Employees' Health Insurance Plan Provider Screening Plan IB13 Step 7: Enter your date of birth in the sixth blank box.

 

Alabama State Employees' Health Insurance Plan Provider Screening Plan IB13 Step 8: Enter your daytime phone number, including the area code, in the seventh blank box.

 

Alabama State Employees' Health Insurance Plan Provider Screening Plan IB13 Step 9: Indicate your race/ethnicity with a check mark.

 

Alabama State Employees' Health Insurance Plan Provider Screening Plan IB13 Step 10: Indicate whether you have or have been told you have high cholesterol, high blood pressure or diabetes with a check mark.

 

Alabama State Employees' Health Insurance Plan Provider Screening Plan IB13 Step 11: Indicate whether you take medication for high cholesterol, high blood pressure or diabetes with a check mark.

 

Alabama State Employees' Health Insurance Plan Provider Screening Plan IB13 Step 12: Submit the form to your provider, who should complete Section 2 by providing all information requested, then printing and signing their name and their address.

 

Alabama State Employees' Health Insurance Plan Provider Screening Plan IB13 Step 13: Mail the form to the address given at the bottom of the page.

 

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