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The Health Risk Assessment form is a vital tool designed to help Passport Health Plan better understand and meet your healthcare needs. By taking a few moments to fill it out, you provide essential information that will enhance your access to benefits and special programs tailored specifically for you. Your privacy is honored; all responses remain confidential and will not impact your benefits. The form covers a variety of important topics, including personal information like your name, address, and contact details, as well as health-related inquiries that address both physical and emotional well-being. It even includes sections on preventive health measures, encouraging you to reflect on your habits such as smoking or seeking medical exams. Additionally, questions regarding your primary care provider and any prior health issues allow for a holistic view of your current health status. The Health Risk Assessment is not just a form; it is a bridge to ensure that you receive the most appropriate and effective care possible.

Health Risk Assessment Example

Health Risk

Assessment Form

Now that you are a member of Passport Health Plan, we ask that you please fill out this form. It will help us see how we can best serve you with our benefits and special programs. Your answers on this form will be kept private. They will not affect your benefits in any way. If you need help filling out this form, please call 1-877-903-0082. TDD/TTY users may call 1-800-691-5566.

Date ___________________________________________

Name (first) _______________________ (middle initial) _____ (last) ___________________________________

Address ___________________________________________________________ Apt # _______________________

City _________________________________________________ State

____________ Zip _________________

Daytime Phone _______________________________________________

Date of birth _______________________

Last four digits of your Social Security #: ____________________

 

Passport Health Plan ID number: ____________________________________________________________________

What is the name of your primary care provider (PCP)? __________________________________________________

What is your PCP’s phone number? __________________________________________________________________

Do you need help choosing a PCP or making an appointment with your PCP?

q Yes

q No

What is your preferred language?

 

 

q English

q Somali

q Spanish

q Russian

q Swahili

q French

What is your gender?

q Male

What is your race? (optional)

 

qArabic

qMandarin

qFemale

qVietnamese

qSign

qBosnian

qOther ______________________________

q American Indian/ Alaskian Native q Native Hawaiian/ Pacific Islander

q Asian q Black or African American q Declined to Answer

qWhite

qOther________________________

What is your ethnicity? (optional)

q Hispanic

q Non-Hispanic

Are you pregnant?

q Yes

q Other________________________

q Declined to Answer

qNo

If yes, what is the name of your OB provider (doctor who cares for you during pregnancy)? _________________________________

What is your OB’s phone number? _______________________________________________________________________

If you are pregnant and do not have an OB provider, do you need help choosing one?

qYes

qNo

When was your last physical exam? __________________________________________________________________

What is your current height? ___________ What is your current weight? ________________

Section One: Physical and Behavioral Health

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1.

In general, would you say your health is:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(circle one number)

 

 

 

 

1

2

 

 

3

 

 

4

 

5

 

 

1 - Excellent

2 - Very Good 3 - Good 4 - Fair 5 - Poor

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The following are activities you might do during a normal day. Please circle one of the numbers to describe

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

how much your health limits you in any of these activities.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1 - Yes, limited a lot

2 - Yes, limited a little

3 - No, not limited

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(circle one number on each line)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf.

 

 

1

2

 

 

 

3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

2

 

 

 

3

 

 

 

 

 

 

 

 

3.

Climbing several flights of stairs.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

During the past 4 weeks, have you had any of the following problems with your work or daily activities as a

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

result of your physical health?

 

 

 

 

q Yes

q No

 

 

 

4.

Could not get done as much as I would like.

 

 

 

 

q Yes

q No

 

 

 

5.

Was limited in the kind of work or other activities.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

During the past 4 weeks, have you had any of the following problems with your work or daily activities as a

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

result of any emotional problems (such as feeling depressed or anxious)?

 

 

 

q Yes

q No

 

 

 

6.

Could not get done as much as I would like.

 

 

 

 

q Yes

q No

 

 

 

7.

Did not do work or other activities as carefully as usual.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8. During the past 4 weeks, how much did pain get in the way of your normal work (including both work

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

outside the home and housework)?

 

 

 

1

2

 

 

3

 

4

 

5

 

 

1 - Not at all

2 - Slightly 3 - Moderately

4 - Quite a bit 5 - Extremely

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(circle one number)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

These questions are about how you feel and how things have been with you during the past 4 weeks. For

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

each question, please give the one answer that comes closest to the way you have been feeling.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1 - All of the time

2 - Most of the time 3 - A good bit of the time

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4 - Some

5 - A little of the time 6 - None of the time

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

During the past 4 weeks, how often: (circle one number on each line)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9.

Have you felt calm and peaceful?

 

 

1

2

3

 

 

4

 

 

 

5

 

6

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10.

Did you have a lot of energy?

 

 

 

1

2

3

 

 

4

 

 

 

5

 

6

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11.

Have you felt sad or down?

 

 

 

 

1

2

3

 

 

4

 

 

 

 

5

 

6

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12.

During the past 4 weeks, how often has your physical health or emotional problems gotten in the way of

 

1

2

3

 

 

4

 

 

5

 

6

 

 

your social activities (such as visiting with friends, relatives, etc.)?

 

 

 

q Yes

q No

 

 

 

13.

Have you seen a psychiatrist or any other mental/emotional health provider previously?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

q Yes

q No

 

 

 

14.

Have you ever been in a psychiatric facility?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

q Yes

q No

 

 

 

15.

Are you on any behavioral health medicines?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If yes, what are they? _____________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

q Yes

q No

 

 

 

16.

Have you ever been treated for substance abuse (alcohol, drugs)?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

q Yes

q No

 

 

 

17.

Do you need help getting a counselor, therapist, or psychiatrist?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

q Yes

q No

 

 

 

18.

Do you need help getting food, clothing or housing?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

19.Has the doctor EVER told you that you had any of the following conditions? (check YES or NO for each line)

 

q Yes

q No

a.

Congestive heart failure

 

q Yes

q No

b.

Chronic lung disease (including bronchitis, emphysema or COPD)

 

q Yes

q No

c.

Diabetes Mellitus (sugar diabetes)

 

q Yes q No

d.

Asthma

 

q Yes

q No

e.

Sickle Cell

 

q Yes

q No

f.

HIV/AIDS

 

q Yes

q No

g.

Hypertension (high blood pressure)

 

q Yes

q No

h.

Heart attack

 

q Yes

q No

i.

Stroke

 

q Yes

q No

j.

End stage kidney disease requiring dialysis

 

q Yes q No

k.

Cancer

 

q Yes

q No

l.

Autoimmune disorders (rheumatoid arthritis, lupus, multiple sclerosis)

 

q Yes q No

m.

Dementia

 

q Yes

q No

n.

End stage liver disease

 

q Yes

q No

o.

Blood disorders, clotting disorders

 

q Yes

q No

p.

Neurologic disorders

 

q Yes

q No

q.

Cardiovascular disorders

 

q Yes

q No

r.

Chronic mental health conditions

 

q Yes q No

s.

Smoker’s cough

 

q Yes

q No

t.

Chronic kidney disease

 

 

 

 

 

 

 

 

 

 

 

 

 

q Yes

q No

20.

Compared to one year ago, my health in general is much worse.

 

 

 

 

 

 

 

 

 

 

 

 

Section Two: Preventive Health

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

2

 

 

3

 

 

1.

How would you describe your smoking habits?

 

 

 

 

 

 

 

 

 

 

 

1

- Still smoke

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2

- Used to smoke

 

 

 

 

 

 

 

 

 

 

 

3

- Never smoked

 

 

 

 

 

 

 

 

 

 

 

 

1

2

 

3

 

4

 

 

2.

How long has it been since your last tetanus shot?

 

 

 

 

 

 

 

 

 

 

 

1

– Within the last year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2

– Within the last 10 years

 

 

 

 

 

 

 

 

 

 

 

3

– More than 10 years ago

 

 

 

 

 

 

 

 

 

 

 

4

– Do not know

 

 

 

 

 

 

 

 

 

 

 

 

 

1

2

 

3

 

 

4

 

 

3.

How long has it been since your last flu shot?

 

 

 

 

 

 

 

 

 

 

 

1

– Within the last 6 months

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2

– Within the last year

 

 

 

 

 

 

 

 

 

 

 

3

– Do not know

 

 

 

 

 

 

 

 

 

 

 

4

– Never

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(If your age is 50 or over)

1

 

2

 

3

 

4

 

5

4. How long has it been since your last colorectal exam (including colonoscopy, stool blood test)?

 

 

 

 

 

 

 

 

 

1

– less than 1 year ago

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2

– 1 year ago

 

 

 

 

 

 

 

 

 

3

– 2 years ago

 

 

 

 

 

 

 

 

 

4

– 3 or more years ago

 

 

 

 

 

 

 

 

 

5

– Never

 

 

 

 

 

 

 

 

 

 

 

(If your age is 18 or over)

1

2

3

 

4

 

5

 

5. How long has it been since your last dilated retinal exam (eye exam by an eye specialist)?

 

 

 

 

 

 

 

 

 

 

1

– less than 1 year ago

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2

– 1 year ago

 

 

 

 

 

 

 

 

 

 

3

– 2 years ago

 

 

 

 

 

 

 

 

 

 

4

– 3 or more years ago

 

 

 

 

 

 

 

 

 

 

5

– Never

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Women Only

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(If your age is 40 or over)

 

1

2

3

4

5

 

6

 

6. How long has it been since your last mammogram (a test for breast cancer)?

 

 

 

 

 

 

 

 

 

 

 

1

– Less than 1 year ago

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2

– 1 year ago

 

 

 

 

 

 

 

 

 

 

3

– 2 years ago

 

 

 

 

 

 

 

 

 

 

4

– 3 or more years ago

 

 

 

 

 

 

 

 

 

 

5

– Never

 

 

 

 

 

 

 

 

 

 

6

– I have had both breasts removed

(If your age is 21 and over)

12 3 4 5 67. How long has it been since you had a Pap smear (test for cervical cancer)?

1 – less than 1 year ago

2 – 1 year ago

3 – 2 years ago

4 – 3 or more years ago

5 – Never

6 – I have had a hysterectomy

Men Only

1 2 3 4 5

8.How long has it been since you had a rectal or prostate exam? 1 – less than 1 year ago

2 – 1 year ago

3 – 2 years ago

4 – 3 or more years ago

5 – Never

Thank you for filling out the Health Risk Assessment!

Please mail this back in the white postage-paid envelope we sent you, or to the following address: Passport Health Plan

Attn: Health Risk Assessment

5100 Commerce Crossings Drive Louisville, KY 40229

Form Characteristics

Fact Name Details
Purpose The Health Risk Assessment form is designed to help the Passport Health Plan understand the needs of its members and provide appropriate services and benefits.
Privacy Assurance Your responses on the form will remain confidential and will not impact your benefits with Passport Health Plan.
Language Options The form allows members to indicate their preferred language, providing inclusivity for various communities, such as English, Somali, Spanish, and others.
Support Accessibility Members can call a dedicated support line at 1-877-903-0082 if they need assistance in completing the form. TDD/TTY users may use 1-800-691-5566 for support.
State-Specific Laws For Kentucky, the Health Risk Assessment form is governed by KRS 205.520, which relates to the administration and regulation of health insurance plans.

Guidelines on Utilizing Health Risk Assessment

Your participation in the Health Risk Assessment is vital. Completing this form allows Passport Health Plan to tailor its services to better meet your health needs. Your personal information will remain confidential, and it will not impact your benefits. If you need assistance during the process, do not hesitate to reach out to the helpline provided.

  1. Start by writing the current date in the designated space provided at the top of the form.
  2. Fill in your full name, including first name, middle initial, and last name.
  3. Provide your complete address, including apartment number, city, state, and zip code.
  4. Enter your daytime phone number, making sure it’s a number you can be reached at easily.
  5. Add your date of birth in the format requested.
  6. Fill in the last four digits of your Social Security number.
  7. Enter your Passport Health Plan ID number as instructed.
  8. Indicate the name and phone number of your primary care provider (PCP).
  9. Answer whether you need assistance choosing a PCP or making an appointment.
  10. Select your preferred language from the provided options.
  11. Indicate your gender on the form.
  12. Complete the race and ethnicity sections, noting that these questions are optional.
  13. Answer whether you are pregnant and provide details about your OB provider if applicable.
  14. Record the date of your last physical exam along with your current height and weight.
  15. Respond to questions about your physical and behavioral health as indicated, ensuring you circle the appropriate options.
  16. Complete the preventive health section, providing accurate responses about your medical history and vaccination status.
  17. Review your answers to ensure everything is correct.
  18. Mail the completed form using the prepaid envelope provided or send it to the specified address.

What You Should Know About This Form

What is the purpose of the Health Risk Assessment form?

The Health Risk Assessment form is designed to help Passport Health Plan understand your health needs better. By gathering information about your physical and emotional health, the plan can tailor its services and benefits to better serve you. Your responses are confidential and will not impact your benefits.

How do I fill out the Health Risk Assessment form?

To fill out the form, provide your personal information such as name, address, date of birth, and contact details. Answer questions regarding your health status, lifestyle, and any healthcare providers you may have. If you need assistance while filling out the form, you can call 1-877-903-0082 for support.

Will my answers affect my benefits?

No, your answers on the Health Risk Assessment form will not affect your benefits in any way. The information is used solely to enhance the services Passport Health Plan can provide to you.

What if I need help completing the form?

If you encounter any difficulties while completing the form, assistance is available. You can call the support line at 1-877-903-0082 or use TDD/TTY at 1-800-691-5566 for help.

Is my personal information confidential?

Yes, your personal information will be kept private. The Health Risk Assessment form is secure, and any data shared will be protected according to privacy laws and regulations.

What happens if I don’t want to answer certain questions?

You are not required to answer every question, especially those marked as optional. If you feel uncomfortable responding to a particular question, you may choose to decline, and it will not impact your membership or benefits.

Where do I send the completed form?

After completing the form, return it using the provided white postage-paid envelope. Alternatively, you can mail it to Passport Health Plan at the following address: Attn: Health Risk Assessment, 5100 Commerce Crossings Drive, Louisville, KY 40229.

How is the information from the form used?

The information collected from your form helps Passport Health Plan identify any health risks or requirements you may have. This allows for the delivery of appropriate programs and benefits catered to your specific health needs and concerns.

Who should I contact for further questions about the Health Risk Assessment form?

If you have any additional questions about the Health Risk Assessment or your health plan, you can contact customer service at 1-877-903-0082. They are available to assist you with any inquiries you may have.

What if I want to change my information later?

If you need to update or change your information after submitting the form, reach out to Passport Health Plan customer service. They can assist you in ensuring that your records are accurate and up-to-date.

Common mistakes

Completing the Health Risk Assessment form is an important step in receiving the best possible care, but many people make mistakes that can hinder the process. One common error is neglecting to fill out all required fields. Omitting essential information like your name or date of birth can delay your application and affect the services you receive.

Another frequent mistake is providing outdated or incorrect contact information. If your address or phone number has changed and you fail to update it, health providers may struggle to reach you when important information or appointments arise. Always double-check your entries for accuracy.

Many individuals also mistakenly skip questions that seem optional. While some sections, such as race or ethnicity, are marked optional, answering them can help healthcare providers understand your needs better. These details may play a crucial role in offering tailored resources and support.

Another serious oversight occurs when individuals do not disclose all health conditions or previous treatments. If you have a chronic condition or have been treated for substance abuse, it’s crucial to provide this information. Failing to do so can lead to inadequate care or the wrong treatment plans being suggested.

Some people forget to answer the emotional health sections, which can be just as important as physical health in assessing your overall wellness. Ignoring these questions might prevent providers from addressing mental health needs effectively, which are vital to your holistic health.

Using vague answers is also a mistake that can create confusion. For instance, instead of saying “pretty good” when asked about your health, use the scale provided. This helps healthcare professionals understand your precise condition and craft a suitable care plan.

Another common error is disregarding instructions for certain sections, such as not providing the correct timeframe for recent medical exams. If you indicate you had a colonoscopy but fail to specify how long ago, it could lead to misunderstandings regarding follow-up care.

It's also worth noting that people occasionally hesitate to seek help when filling out the form. There’s no shame in reaching out for assistance, whether from a family member or the helpline provided. They can clarify some of the terms or questions that might feel daunting.

Finally, neglecting to sign and date the form can result in it being considered incomplete. Always take a moment to ensure that every part of the form is filled out, reviewed, and properly submitted. Doing so allows healthcare providers to serve you more effectively.

Documents used along the form

The Health Risk Assessment form is an essential tool for understanding a member's health needs and ensuring appropriate care. Several additional documents often accompany this form to provide more comprehensive information. Below is a list of commonly used forms that support the assessment and registration process.

  • Insurance Enrollment Form: This document provides necessary personal details to enroll in health insurance. It includes information such as coverage selection, dependent details, and other vital data needed for policy creation.
  • Release of Information Form: It allows the healthcare provider to share a patient's medical data with relevant parties. This is essential for coordinating care and ensuring that all parties have access to necessary health information.
  • Patient Registration Form: Typically includes demographic information, medical history, and preferences related to care. It establishes the patient’s profile for the healthcare provider's records.
  • Advance Directive: This legal document specifies a person’s wishes regarding medical treatment in case they are unable to communicate those wishes themselves. It covers topics like life-sustaining treatment and end-of-life care decisions.
  • Medication Reconciliation Form: Used to list all medications a patient is currently taking. Ensuring accurate medication management is crucial for providing safe and effective care.

Understanding these documents can streamline your healthcare experience. Each plays a distinct role in facilitating effective communication and care within the healthcare system.

Similar forms

The Health Risk Assessment form serves an important role in evaluating an individual's health and healthcare needs. Here are four documents it is similar to, along with explanations of those similarities:

  • Health History Questionnaire: Like the Health Risk Assessment form, a Health History Questionnaire collects detailed information about a person's past and current health conditions, lifestyle choices, and any medications they are taking. Both forms aim to provide healthcare providers with essential context for tailored care.
  • Patient Intake Form: This document shares a similar purpose with the Health Risk Assessment. Both forms are filled out by patients before their appointments to help healthcare providers understand their medical history, current symptoms, and any specific concerns they may have. This can lead to better patient-provider interactions.
  • Behavioral Health Assessment: A Behavioral Health Assessment also targets the mental and emotional health of an individual, much like the Health Risk Assessment. Both assessments include questions about emotional well-being and can help in identifying any immediate needs for mental health support, promoting holistic care.
  • Preventive Health Checklist: Similar to the Health Risk Assessment which includes preventive questions like immunization history, a Preventive Health Checklist also aims to ensure that an individual is current on critical health screenings and vaccinations. Both emphasize the importance of preventive care as part of overall health management.

Dos and Don'ts

When filling out the Health Risk Assessment form, there are important dos and don’ts to consider. Following these guidelines will help ensure your form is correctly processed and your information is accurately captured.

  • Do fill out the form completely and accurately.
  • Do use clear handwriting or type your responses if possible.
  • Do double-check your Social Security number and Passport Health Plan ID number for accuracy.
  • Do provide your preferred language to help facilitate communication.
  • Don’t leave any mandatory fields blank.
  • Don’t disclose personal information that is not required by the form.
  • Don’t rush through the questions—take your time to reflect on your answers.
  • Don’t forget to sign and date the form before submitting it.

Ensure your responses are truthful and thorough. If any questions are unclear or you need assistance, do not hesitate to call the provided support numbers. Your health and well-being are priorities, and accurate information will help in serving you better.

Misconceptions

  • Misconception 1: The Health Risk Assessment (HRA) form is mandatory for all members.
  • This form is not mandatory. Though filling it out helps the plan understand your needs, members can opt not to submit it.

  • Misconception 2: Answers on the HRA form affect your benefits.
  • Your responses will not have any impact on your benefits. They are used solely to tailor services to better support your health.

  • Misconception 3: The information provided is not kept private.
  • All answers will remain confidential. Your privacy is a priority, and information will only be used to enhance your care.

  • Misconception 4: The HRA form is complicated and hard to understand.
  • The HRA is designed to be straightforward, with clear questions and options to select. Assistance is available if needed.

  • Misconception 5: You must fill out all the information, including optional questions.
  • While certain fields are mandatory, you can skip questions marked as optional, such as race and ethnicity.

  • Misconception 6: Submitting the HRA form is the only way to access care services.
  • This form helps identify needs but is not the sole avenue to access care. Members can seek services without completing it.

  • Misconception 7: Only members with existing health issues need to fill out the HRA.
  • The HRA is useful for all members, regardless of their current health status. It helps identify potential needs for preventive care.

Key takeaways

The Health Risk Assessment (HRA) form is an important tool for members of Passport Health Plan. Here are some key takeaways to guide you in filling it out and using it effectively.

  • Confidentiality: Your answers on the HRA form are private and will not affect your benefits in any way. This ensures you can provide honest and complete information.
  • Assistance is available: If you need help while filling out the form, call 1-877-903-0082. TDD/TTY users should call 1-800-691-5566 for support.
  • Thorough information: Provide your personal details, including name, address, phone number, date of birth, and the last four digits of your Social Security number. This information is essential for your health assessment.
  • Primary Care Provider: Indicate the name and contact information of your primary care provider (PCP). This allows for better coordination of care.
  • Health concerns: Answer questions about your physical and emotional health accurately. This helps identify any limitations in your daily activities.
  • Preventive care: The form includes questions about your preventive health measures, such as vaccinations and screenings. Keeping your health up to date is crucial.
  • Help with resources: If you need assistance with food, clothing, or housing, indicate this on the form. Resources may be available to support you.
  • Optional demographics: Providing information regarding your race and ethnicity is optional. However, this data can help understand health disparities and improve services.
  • Returning the form: Mail your completed form back using the white postage-paid envelope provided, or send it to the designated address for Passport Health Plan.
  • Health tracking: Compare your current health status to last year. This reflection can be beneficial for recognizing changes and discussing them with your healthcare provider.

Completing the HRA form is a vital step towards ensuring you receive the best possible care tailored to your needs.