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Fill Out Your Inova Health Screening Form

The Inova Health Screening form is a document required for individuals undergoing health assessments at Inova facilities. This form collects essential personal and medical information from employees, spouses, or domestic partners who desire laboratory testing. To begin your health screening journey, please fill out the form by clicking the button below.

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Fill Out Your Inova Health Screening Form

Article Structure

The Inova Health Screening form is a crucial document for individuals wishing to participate in health assessments offered by Inova. It captures essential patient information including personal details such as name, address, and contact information, alongside their employment information. The form also requires the patient to provide details about their physician, ensuring a comprehensive record of their medical background. Consent is a key aspect, as participants agree to submit their samples for blood tests conducted by Health Diagnostic Laboratory, Inc. (HDL). This consent emphasizes that the tests are informational, and should not be seen as a substitute for professional medical advice or treatment. Privacy is another important factor, with patients acknowledging their understanding of HDL's Notice of Privacy Practices. The form includes instructions for completion, indicating that it must be printed, signed, and brought to the health assessment appointment, while also prohibiting handwritten submissions. Additionally, patients are prompted to provide their biometrics, which include height, weight, blood pressure, and waist circumference, highlighting the form's role in establishing a baseline for health assessments. By clearly outlining these components, the Inova Health Screening form serves not only as a means of gathering necessary health information but also as a tool for promoting awareness regarding personal health responsibilities.

Inova Health Screening Example


«Please select one
Employee Spouse or Domestic Partner

PATIENT ID	«		ID	«	HISTORY
	EMPLOYEE			«
				Did you participate in the Inova Health
				Screening in 2014? Yes  No 
	PATIENT INFORMATION
«Last Name:		First:			Middle Iniial:

«Address (Home or Mailing):

	«City:					«State:		«Zip Code:
	«Primary Phone:					«Date of Birth:			«Age:
(				)	-	/	/
		«Secondary Phone:				«Sex:
(				)	-	M		F
			«Email:			«Employer Name:
					YOUR PHYSICIAN	INFORMATION
«Physician’s Name:						«Pracice Name:

«Pracice Phone Number:

PATIENT CONSENT

I consent to submit my sample to Health Diagnostic Laboratory, Inc (“HDL”) for testing. HDL works with physicians who will order your laboratory test(s) when medically appropriate. These physicians will not diagnose or treat you. The blood testing service from HDL (a) is provided solely for informational purposes and does not constitute treatment or diagnosis of any medical condition or the practice of medicine; and (b) 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. HDL and HDL physicians shall not be liable for your failure to consult with your primary care physician or another medical professional following receipt of test results. 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. I have read the above terms and conditions and agree to them.


	/	/
	/	/
Patient Signature	Date

	NOTICE OF PRIVACY PRACTICES

I acknowledge that I have reviewed HDL Notice of Privacy Practices and understand that it may be revised from time to time. I understand that any changes will be posted on HDL’s website, www.hdlabinc.com, and that I am entitled to receive a copy of the notice upon request.

«	/	/
Patient Signature	Date

Office Use Only:

We attempted, but could not obtain written acknowledgment of receipt of our Notice of Privacy Practices, because:

Patient refused to sign

Emergency Situation

Other:__________________________________________________________________________________

PHLEBOTOMIST USE ONLY

Has the Paricipant previously had their

YES

If yes, where?

labs drawn by HDL?

Is the Paricipant

YES

Does the Paricipant have a

YES

pregnant?

pacemaker?

Biometrics

Drawing Lab:

Height:

feet

inches

Tel. No.:

)

Weight:

(

ext:

pounds

Collecion Date & Time:

Blood

Pressure

am/pm

(mm/Hg):

Systolic

Diastolic

Phlebotomist

Waist

Circumference

(inches):

inches

Fasing:

Yes

Body Composiion (%):

Hrs

Internal Use Only:  All fields with a «are complete.

Location is checked.

Phlebotomist Use Only is complete.

Initial:_______ Date:________

*INSTRUCTIONS:

This form MUST be typed, signed, printed and brought to your health assessment appointment. Handwritten copies will NOT be accepted.

REQUESTING LAB/INSTITUTION

Inova WellAware Health Screening	V1.3
Inova WellAware Health Screening
HDL Overseeing Physician: Thomas D. Dayspring, MD

«Please select your location of employment, or "spouse" if applicable

Inova Fairfax Medical Campus - 0010898

Inova Alexandria Hospital - 0010899

Inova Fair Oaks Hosptial - 0010900

Inova Loudon Hosptial - 0010901

Inova Mount Vernon Hospital - 0010902

Inova Medical Group - 0010903

Inova Continuum of Care - 0010905

Inova Healthplex-Urgent Care Centers - 0010906

Inova System Office - 0010904

Inova Spouse-Domestic Partner - 0010907

CUSTOM PANELS

Custom Employer Panel

Lipid Panel hsCRP Insulin Glucose HbA1c

TSH

ALT Creatinine Cystatin C LDL-P & HDL-P

Joseph P. McConnell, Laboratory Director 737 N. 5th Street, Suite 103

Richmond, VA 23219

CLIA No. 49D1100708 | CAP No. 7224971 | NPI No.

1629209853

Get Inova Health Screening PDF Form

Form Characteristics

Fact Name	Details
Form Purpose	The Inova Health Screening form is used for patients to provide necessary information to undergo health screening tests.
Patient Information Required	Patients must fill in personal details, such as name, address, date of birth, contact information, and physician details.
Consent for Testing	Patients consent to submit their samples for testing, acknowledging that results are for informational purposes only and do not replace professional medical advice.
Privacy Acknowledgment	Patients must acknowledge receipt of the Notice of Privacy Practices, which explains how their information will be used and protected.
Laboratory Information	The testing is conducted by Health Diagnostic Laboratory, Inc. (HDL), and patients are responsible for forwarding results to their primary care physician.
Form Completion Requirement	This form must be typed and printed; handwritten forms will not be accepted at the health assessment appointment.
Compliance with Regulations	Inova Health Screening practices adhere to state health regulations, ensuring patient rights and privacy in healthcare services.

Guidelines on Utilizing Inova Health Screening

Completing the Inova Health Screening form is necessary for your upcoming health assessment appointment. This process ensures that all relevant information is accurately captured, allowing for a smooth and efficient experience. Follow the steps below to fill out the form correctly.

Select your status as either Employee, Spouse, or Domestic Partner.
Fill in your Patient ID.
Indicate if you participated in the Inova Health Screening in 2014 by selecting Yes or No.
Complete the Patient Information section with your last name, first name, middle initial, address, city, state, zip code, primary phone number, date of birth, age, secondary phone number, sex (select M or F), email, and employer name.
In the Your Physician Information section, provide your physician’s name, practice name, and practice phone number.
Review the Patient Consent statement. If you agree, sign and date it.
Acknowledge that you have reviewed the Notice of Privacy Practices by signing and dating that section.
For office use, indicate the reasons if acknowledgment of the Notice of Privacy Practices was not obtained.
In the Phlebotomist Use Only section, check if you have previously had labs drawn by HDL, if you are pregnant, and if you have a pacemaker, answering Yes or No as appropriate.
Fill in the Biometrics Drawing Lab section with your height, weight, blood pressure, waist circumference, and body composition.
Ensure that all fields marked with a « are complete and initial the form in the designated area.
Finally, bring your completed form to your health assessment appointment—ensure it is typed, signed, and printed, as handwritten forms will not be accepted.

What You Should Know About This Form

What is the purpose of the Inova Health Screening form?

The Inova Health Screening form is designed for patients who wish to participate in health screenings offered by Inova. It collects essential personal and medical information to ensure that the testing can be conducted safely and effectively. The information helps healthcare providers understand the patient’s health history and requirements, allowing them to provide better support during the testing process.

Who can fill out the Inova Health Screening form?

This form can be filled out by employees of Inova, their spouses, or domestic partners. The patient must provide their personal details, such as name, age, and contact information, as well as details about their physician. It's crucial for the form to be complete and accurate to proceed with health screening services.

Why does the form ask if the patient participated in the Inova Health Screening in 2014?

This question helps the healthcare providers track the patient’s health history over time. Participation in previous screenings can provide insight into health trends and changes. This information might be beneficial for the healthcare professionals reviewing the laboratory results and analyzing the patient’s overall health journey.

What happens with the test results from HDL?

The test results from Health Diagnostic Laboratory, Inc. (HDL) are for informational purposes only. HDL does not diagnose or treat any medical conditions. Patients are responsible for discussing their results with their primary care physician, ensuring they receive the appropriate care and advice based on those results.

What should I do if I have questions about the tests being performed?

If you have questions about the specific tests being conducted, it is important to directly consult with the healthcare providers involved in your screening. They can clarify the types of tests, their purposes, and how the results will be interpreted. It is essential to have a thorough understanding to make informed health decisions.

Are the costs of these tests covered by insurance?

No, the costs of the tests from HDL are not billed to Medicare, Medicaid, or private insurance. Participants should be aware that the testing is privately paid for by the patient or their employer. This can affect how you plan for the financial aspect of your health screening, so make arrangements accordingly.

What should I do if I lose my Inova Health Screening form?

If you lose your Inova Health Screening form, it's advisable to contact Inova’s support team or your human resources department. They can provide guidance on how to obtain a replacement form or instructions for filling out a new one. Remember, handwritten forms are not accepted, so you will need to use a typed version.

Common mistakes

Filling out the Inova Health Screening form can be straightforward, but mistakes often occur. One common error is selecting the wrong participant type. Individuals may accidentally check the box for "Spouse" instead of "Employee" or vice versa. This choice affects how the information is processed and can lead to confusion during the screening.

Another frequent mistake involves incomplete personal information. Participants sometimes forget to fill in essential details such as the date of birth, address, or contact information. Missing this information can delay the processing of results. Always ensure all required fields, marked with a star, are filled out correctly.

Participants often overlook the section regarding their primary physician. This part is crucial, as it ensures that test results are sent to the appropriate medical professional for future consultations. Not providing this information can lead to a lack of follow-up care, which is essential for health management.

A significant mistake is related to patient consent. Some individuals may not fully read or understand the consent agreement with HDL. Not acknowledging these terms can lead to complications down the line. It's vital to read the entire consent statement to ensure understanding and agreement to the terms presented.

Failing to sign and date the form is another error that can easily happen. Without a signature, the form is considered incomplete, leading to potential delays in the screening process. Participants must remember that their signature indicates agreement and acknowledgment of the information provided.

Participants sometimes misplace or forget to include some specific health information, such as whether they have a pacemaker or are pregnant. This information is critical for the safety and accuracy of the health screening. Omitting it can compromise the test results or the care that follows.

Finally, many individuals do not realize that the form must be typed. Submitting a handwritten form will result in automatic rejection. Therefore, it is essential to take the time to fill it out using a computer before printing it for the health assessment appointment.

Documents used along the form

The Inova Health Screening form is an essential document for individuals participating in health assessments. However, several other forms and documents often accompany it to ensure a comprehensive evaluation of health status. These additional documents serve various purposes, from confirming consent to detailing privacy practices.

Informed Consent Form: This document explicitly states that participants understand the nature of the tests and agree to undergo them. It provides necessary legal protection to the healthcare provider and outlines patient rights.
Health History Questionnaire: Patients fill out this form to provide details about their past medical histories, including surgeries, chronic conditions, and medications. This information helps healthcare providers make informed decisions about care.
HIPAA Privacy Acknowledgment: Patients sign this document to confirm understanding of their rights under the Health Insurance Portability and Accountability Act. It covers how their health information will be used and protected.
Identification Verification Form: In many cases, patients are required to submit a form verifying their identity. This could include a driver's license or another form of official ID to ensure that the correct person is undergoing testing.
Financial Responsibility Agreement: This outlines the responsibilities of the patient regarding payment for the services provided. Patients must understand if their insurance will cover the tests or if they will pay out of pocket.
Test Result Release Authorization: This form allows the healthcare provider to share testing results with specified individuals, such as a primary care physician. It ensures that the patient's privacy is maintained while allowing necessary communication.
Emergency Contact Form: Patients provide contact information for someone who can be reached in case of an emergency. This ensures healthcare providers can make timely decisions if the patient encounters any issues during the screening.
Lab Order Form: This document is used by healthcare providers to indicate specific tests to be conducted. It assures that the lab receives clear instructions about what assessments are to be performed.
Follow-Up Care Plan: After screening completion, this plan outlines any recommended next steps, additional tests, or referrals required based on the results. It helps ensure continuity of care and patient understanding.
Feedback and Satisfaction Survey: Patients may be asked to complete a survey about their experience. Insights gathered help improve services and address any concerns raised during the health screening process.

By utilizing these accompanying documents, the health screening process becomes more effective and transparent for both patients and healthcare providers. Understanding these forms enhances patient agency and fosters a better communication channel within the healthcare system.

Similar forms

Medical History Form: This document collects patient details like personal information, medical history, and existing conditions in a format similar to the Inova Health Screening form. Both forms require essential patient information for healthcare providers to make informed decisions.
Consent Form: Similar to the consent section in the Health Screening form, this document requires signatures to affirm that patients understand the procedures and agree to testing. Both forms outline the responsibilities and liabilities associated with medical testing.
Patient Registration Form: This form captures basic demographic and insurance information, akin to the patient identification section of the Inova form. Both serve to identify the patient and facilitate future communications with healthcare providers.
Insurance Information Form: Like the Inova Health Screening form, this document collects insurance details to confirm coverage. Both forms emphasize the need for clear financial arrangements related to health services.
Laboratory Test Requisition Form: This document requests specific tests to be performed and is similar in function to the Inova Health Screening form’s request for testing consent. Both ensure that the appropriate tests are administered based on patient needs.
Phlebotomy Consent Form: This document, which many patients sign before blood draws, is comparable to the consent section in the Health Screening form. Both outline the procedure and confirm the patient's understanding of the blood testing process.
Privacy Notice Acknowledgment: Patients acknowledge receipt of privacy policies in both forms. Each document informs patients of how their personal health information will be used and protected, promoting transparency.
Follow-up Appointment Request Form: Similar to the scheduling information included in the Inova form, this document helps set future appointments. Both are critical in ensuring continuity of care following screenings or tests.

Dos and Don'ts

When filling out the Inova Health Screening form, individuals should consider the following guidelines:

Provide accurate and complete patient information to avoid delays in processing.
Ensure that the signature and date fields are appropriately filled to validate consent.
Review the Notice of Privacy Practices and acknowledge understanding in writing.
Type the entire form; handwritten entries are not accepted.
Bring the completed form to the health assessment appointment as required.

Conversely, there are certain actions to avoid during this process:

Do not omit any required fields marked with a « symbol.
Avoid providing inaccurate information about medical history or personal details.
Do not forget to bring the form on the day of the appointment.
Refrain from signing the consent if you have not understood the terms.
Do not attempt to submit a handwritten form, as it will not be accepted.

Misconceptions

Misconception 1: The Inova Health Screening form is used for diagnosis and treatment.

This form does not serve to diagnose or treat any medical conditions. Instead, it facilitates testing for informational purposes only. You must seek advice from your primary care physician for any medical issues.

Misconception 2: Medicare or private insurance will cover the costs of the tests.

All tests must be privately paid for by you or your employer. There will be no billing to Medicare, Medicaid, or any private insurance plan.

Misconception 3: Handwritten forms are acceptable.

The form must be typed and printed. Handwritten versions will not be accepted at your health assessment appointment.

Misconception 4: Once I submit the form, I do not need to consider its terms.

You are responsible for understanding the terms outlined in the Patient Consent section. Signing indicates you agree to all terms and conditions included.

Misconception 5: I can skip providing my primary care physician information.

Providing your primary care physician's information is crucial. You will need this for future follow-up concerning your test results.

Misconception 6: The tests are a substitute for my regular medical check-ups.

The tests you undergo through HDL should not replace regular check-ups or consultations with your healthcare provider.

Misconception 7: The health screening test results are confidential.

While the results are shared with you, you must take the initiative to forward them to your primary care physician. The responsibility of confidentiality ultimately lies with you.

Key takeaways

Here are the key takeaways for filling out and using the Inova Health Screening form:

The form must be typed; handwritten submissions will be rejected.
Provide accurate personal information, including your full name, address, and contact details.
Select whether you are an employee, spouse, or domestic partner on the form.
Ensure that your consent for testing is clearly indicated by signing and dating the consent section.
Read the Notice of Privacy Practices and acknowledge your understanding by signing where indicated.
Complete the laboratory biometrics section accurately, including measurements like height, weight, and blood pressure.
Bring a printed and signed copy of the completed form to your health assessment appointment.

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