Article Structure
Understanding the United Healthcare Wellness form is essential for employees of JPMorgan Chase and their covered spouses or domestic partners who want to participate in wellness screenings. This form serves a crucial role in collecting health data that can ultimately benefit participants by facilitating the sharing of results with their healthcare provider and health insurance company. Participants must complete Section 1, providing personal details such as their name, age, and contact information. They also grant permission for their healthcare provider to send this data to Provant Health Solutions, an essential step in the process. Healthcare providers, in return, are responsible for filling out Section 2, where they document important medical details after conducting the wellness screening, including cholesterol levels, blood pressure readings, and other health metrics. This information must be submitted within 31 days, either by fax or email, to ensure timely processing. It is vital for participants to be aware of the implications regarding the sharing of their health information, governed by the Health Insurance Portability and Accountability Act (HIPAA). The submission of this form is not just a procedural step; it also holds significance for eligibility in the Medical Reimbursement Account (MRA) funds and wellness rewards. Thus, participants must ensure accuracy and timely submission to maximize the benefits of the wellness program.
United Healthcare Wellness Example
Wellness Screening Results Form for Health Care Providers
JPMorgan Chase employee and covered spouse/domestic partner: Please have your health care provider complete this form after you receive your Wellness Screening. This form must be faxed or emailed to the address indicated within 31 days of the screening date.
Participant:
Please fill out and sign Section 1. All information is required to process this form. It is your responsibility to ensure that your healthcare provider submits all required information within the requested timing to Provant Health Solutions.
Healthcare Provider:
Please fill out and sign Section 2 and fax within 31 days of the screening date to Provant Health Solutions at (401)
* For purposes of this form, “Healthcare Provider” includes a licensed health professional, for example: MD, DO, PA, or NP.
Section 1: Completed by participant
Name: |
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Employee |
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Spouse/Domestic Partner |
If you are a covered spouse/domestic partner, please list the JPMC employee name:
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Employee Standard ID: |
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Phone Number: __________________________ |
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By signing below, I give my health care provider listed below permission to fax this form to Provant. I also give permission to Provant to share my results with my health care company and the JPMorgan Chase Medical Plan. I understand my screening results will be uploaded to my health care company
submit this form. If you do not submit this form, you will not be eligible for Medical Reimbursement Account (MRA) Funds/Wellness Rewards.
*Note: If are not enrolled in the JPMorgan Chase Medical Plan, Cigna has been designated by the Medical Plan, as your health care company, to administer the program. If you do not want your data shared with Cigna please do not submit this form.
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Section 2: To be completed by health care provider |
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Fasting |
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If you have an office stamp, please apply here: |
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Healthcare Provider’s Name (Please Print) |
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Healthcare Provider’s Signature |
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Do not submit this request form to your Human Resources department. All information provided is kept strictly confidential, is protected by law, and is not disclosed to your employer. Results provided do not preclude eligibility in any benefit program.
© 2014 Provant Health Solutions.
Insurance Portability and Accountability Act (HIPAA) 29 CFR 2590.702 and the Department of Labor (DOL) 29 |
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CFR Part 2590.702(f)(2)(i)(ii)(iii)(iv)(v) of the Nondiscrimination and Wellness Program regulations. |
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Form Characteristics
| Fact Name | Details |
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| Form Purpose | This form collects wellness screening results from healthcare providers for JPMorgan Chase employees and their covered spouses/domestic partners. |
| Submission Deadline | The completed form must be submitted within 31 days of the wellness screening date via fax or email. |
| Required Sections | Section 1 must be filled out by the participant, while Section 2 needs to be completed and signed by the healthcare provider. |
| Privacy Assurance | All information is confidential and protected under HIPAA. It will not be shared without authorization. |
| Healthcare Provider Definition | The form defines "healthcare provider" to include licensed professionals such as MD, DO, PA, or NP. |
| Non-Submission Impact | If the form is not submitted, participants will not be eligible for Medical Reimbursement Account Funds or Wellness Rewards. |
Guidelines on Utilizing United Healthcare Wellness
To effectively complete the United Healthcare Wellness form, participants will need to provide accurate information and ensure that their healthcare provider submits the required sections promptly. Understanding and following these steps will help streamline the process and ensure compliance with submission timelines.
- Obtain the United Healthcare Wellness form from your employer or the designated source.
- Fill out Section 1 as the participant, providing the following required information:
- Name (First, MI, Last)
- Gender: Male or Female
- Status: Indicate if you are an Employee or a Spouse/Domestic Partner, and if applicable, include the JPMC employee’s name.
- Age
- Date of Birth
- Employee Standard ID
- Phone Number
- Sign and date Section 1, granting permission to your healthcare provider to fax the completed form to Provant Health Solutions.
- Provide the completed form to your healthcare provider for Section 2 to be filled out.
- Request your healthcare provider to complete Section 2, which includes:
- Indicating whether the screening was fasting or non-fasting
- Documenting pregnancy status, date of screening, and pertinent health metrics (cholesterol, glucose, blood pressure, height, weight, etc.)
- Have your healthcare provider sign and date Section 2 and apply an office stamp if available.
- Ensure the completed form is faxed to Provant Health Solutions at (401) 336-2898 or emailed to JPMCforms@provanthealth.com within 31 days of the screening date.
What You Should Know About This Form
What is the United Healthcare Wellness form used for?
The United Healthcare Wellness form is designed for JPMorgan Chase employees and their covered spouses or domestic partners. Its primary purpose is to collect and document health screening results. After a wellness screening, participants must have their healthcare provider complete this form and submit it within a specific timeframe to ensure eligibility for certain wellness rewards.
How do I complete the United Healthcare Wellness form?
To complete the form, individuals need to fill out Section 1, which requires personal information such as name, age, and contact details. After this, the healthcare provider will complete Section 2, documenting the health screening results. The form must then be submitted to Provant Health Solutions either by fax or email within 31 days of the screening date.
What happens to my information after I submit the Wellness form?
Your information is kept confidential and is not disclosed to your employer without your authorization. After the form is submitted, the wellness screening results may be uploaded to your healthcare company's secure site. Only you can access this site, where a medical professional may review your results and contact you if needed.
What if I do not want my data shared with Cigna or UnitedHealthcare?
If you prefer not to share your health data with these companies, do not submit the Wellness form. Choosing not to submit it means you will not be eligible for Medical Reimbursement Account funds or wellness rewards.
What is the timeframe for submitting the Wellness form?
The Wellness form must be submitted by your healthcare provider within 31 days of your wellness screening date. This deadline is essential for maintaining your eligibility for the associated health rewards and ensuring the timely processing of your results.
Common mistakes
Completing the United Healthcare Wellness form requires attention to detail. One common mistake people make is not providing all required information in Section 1. Participants should ensure that each field is filled out completely, including personal details such as name, date of birth, and employee standard ID. Omitting even one piece of information can lead to processing delays.
Another frequent error involves signing the form. Some participants forget to sign their names in the designated area. This signature is crucial because it grants permission for the healthcare provider to share results. Without a signature, the form may be considered invalid, preventing the submission from being processed.
Timing is another aspect where mistakes can occur. Participants must remember to submit the completed form within 31 days of their wellness screening. Delays can jeopardize eligibility for Medical Reimbursement Account (MRA) funds or Wellness Rewards. To avoid missing deadlines, setting a reminder soon after the screening is a smart approach.
Healthcare providers are equally important in this process. A common mistake is failing to complete Section 2 accurately. Providers must accurately report all relevant health metrics, including cholesterol levels, blood pressure, and other measurements. Inaccurate or incomplete data can affect the assessment of results and the participant’s health plans.
Addressing privacy concerns is crucial as well. Participants should be aware that they can choose not to have their data shared with Cigna or UnitedHealthCare. However, if they wish to opt out, they must refrain from submitting the form. Otherwise, the data will automatically be shared, potentially leading to unintended consequences.
Using the correct contact information is another key step. Individuals often mistake the fax number or email address listed on the form. The form specifically instructs participants to send it to the correct address, which is Provant Health Solutions. Double-checking this information can prevent misdirected submissions, ensuring that all documents reach the appropriate destination.
Lastly, participants should remember the importance of the healthcare provider's office stamp, if applicable. Some forget to apply their office stamp, which can make the form look incomplete. Adding this stamp where required adds a professional touch and denotes authenticity, which may help streamline the processing of the form.
Documents used along the form
The United Healthcare Wellness form plays a significant role in employee health screenings, but it is not the only document involved in the process. Various forms accompany the wellness screening to ensure a comprehensive approach to health management. Below is a list of commonly used documents that complement the United Healthcare Wellness form.
- Authorization to Release Health Information - This document allows the healthcare provider to share pertinent medical data with relevant parties, such as employers or health insurance companies. It ensures that personal information is handled legally and ethically.
- Medical History Questionnaire - This form collects information about a participant's past health issues, current medications, and family health history. It helps healthcare providers tailor their recommendations based on individual health backgrounds.
- Consent Form for Screening - Participants must often sign this form to give their consent before undergoing health screenings. It explains the procedures involved and any potential risks associated with the screening process.
- Privacy Practices Notice - This document outlines how an organization protects personal health information under HIPAA regulations. It informs participants about their rights regarding confidentiality and data security.
- Health Risk Assessment (HRA) - An HRA is a self-administered questionnaire that evaluates a participant's health risks by exploring lifestyle practices, symptoms, and medical history. It helps in identifying areas for improvement.
- Wellness Program Enrollment Form - This form is used for enrolling in a specific wellness program offered by an employer or health insurer. It typically requires basic personal information and consent to participate.
- Feedback or Satisfaction Survey - After participating in health screenings or wellness programs, participants may be asked to complete a survey. This feedback helps improve future programs and services.
- Medical Reimbursement Account (MRA) Claim Form - Employees may need this document to submit claims for wellness-related expenses. It allows them to access funds from their designated MRA for covered medical expenses.
By understanding these accompanying documents, employees can navigate their wellness initiatives more effectively and take charge of their health journey. Each form contributes uniquely, enhancing the overall health and wellness experience.
Similar forms
The United Healthcare Wellness form shares similarities with several other medical and wellness-related documents. Here are eight documents that bear resemblance to it:
- HIPAA Authorization Form: Like the Wellness form, the HIPAA Authorization Form allows patients to authorize healthcare professionals to share their medical information with specific entities.
- Patient Health Record (PHR): Both documents collect personal health information from patients, enabling better healthcare management and follow-up.
- Insurance Claim Form: The claim form requires detailed patient data to be submitted for reimbursement
Dos and Don'ts
When filling out the United Healthcare Wellness form, there are several important guidelines to follow in order to ensure a smooth and successful submission. Below is a list of things you should and shouldn’t do.
- Do fill out all required sections completely. Your healthcare provider needs accurate information to process the form.
- Do sign the form where indicated to authorize your healthcare provider to submit it on your behalf.
- Do ensure the form is submitted within 31 days of your screening date. Late submissions may not be accepted.
- Do provide a valid email address and phone number. This allows for effective communication about your results.
- Don’t omit any required information. Missing data could lead to processing delays.
- Don’t share your personal health information without understanding your rights under HIPAA. Keep your data secure.
Following these guidelines can help maximize your benefits and maintain your health information’s confidentiality.
Misconceptions
Here are four misconceptions about the United Healthcare Wellness form:
- It is optional to submit the form. Many people believe that submission of the form is optional. In reality, if you do not submit this form, you will not be eligible for Medical Reimbursement Account (MRA) Funds or Wellness Rewards.
- Only employees can fill out the form. Some individuals think that only employees are eligible to complete the form. However, covered spouses and domestic partners can also fill out Section 1 of the form.
- Personal information is shared with JPMorgan Chase. There is a misconception that personal health information will be shared with JPMorgan Chase. The form explicitly states that all information is kept confidential and is not disclosed to your employer without your authorization.
- The form must be submitted to Human Resources. People often assume that the form needs to be submitted to the Human Resources department. This is incorrect. The completed form should be faxed or emailed directly to Provant Health Solutions, not HR.
Key takeaways
Filling out the United Healthcare Wellness form can feel overwhelming, but breaking it down into manageable steps makes the process easier. Here are some key takeaways to keep in mind:
- Timeliness is crucial: After your Wellness Screening, you have 31 days to ensure the completed form is sent to Provant Health Solutions. This applies both to you and your healthcare provider.
- Complete all required sections: Make sure to fill out Section 1 fully. All information provided is essential for processing the form. Without complete information, your submission may be delayed.
- Understand your role: As a participant, you not only need to provide your details, but also give permission to your healthcare provider to share your screening results with Provant Health Solutions.
- Confidentiality matters: Your personal health information is protected by law, and it won’t be shared with others, including your employer, without your authorization.
- Keep copies: This can help you track your submissions. Having a record of your form can provide peace of mind.
- Stay engaged with your health: The results you share may lead to valuable discussions with your healthcare provider about ways to improve your health.
By following these guidelines, you'll help ensure that the process goes smoothly, allowing you to focus on your health and wellness.
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